ORDER APPROVAL FORM

ORDER APPROVAL FORM Tel: COUNTRY FLOORS, INC. 15 E. 16'h Street New York, NY 10003 • Fax: Name: Date: (exactly as it appears on the credit card) Credit Card Billing Address: City State Zip Phone No. ( ) Fax No. ( ) Ship To Address: City State Zip Phone No. ( ) Fax No. ( ) Thank you for your recent order(s) with Country Floors, Inc. Before we can process your order, we require your signature of approval on the following forms. Please read and indicate your approval by signing your sales work order and our terms and conditions of sale. Kindly fax back the signed copies to us along with this form to (MJM N. You can mail your signed sales work order with your payment or complete the credit card authorization information. Please call if you have any questions or if we can be of further assistance. Sincerely, Your Sales Consultant or Administrator CREDIT CARD AUTHORIZATION Total Charges $ Card Type All special and custom orders are non returnable and non refundable. Stock orders may be returned in perfect condition within 30 days of delivery date with 25% restocking fee. K Visa Card No. K Master Card Expiration Date: VIN No. I agree to pay the above amount according to the card issuer agreement. Signature: Date: I 1 MVOS SharcdtOperationsManualTomis1OrderApprovalForm NY.dot EFTA00523030