COMPANY NAME:

CARDHOLDER INFORMATIONName of Cardholder:(as it appears on Card)

Address:

City: State:

Zip Code:

CREDIT CARD INFORMATION

VISA AMEX MASTERCARD

Credit Card Number

Security Code (3 digits on back VS/MC 4 digits in front AMEX)

Expiration Date

INVOICE INFORMATION

Sales Order or Invoice Number:

Total authorized charges

Authorized Signature:

CREDIT CARD

LA SIESTA INC

Miami, FL 33122

Fax: 786-401-1139

3325 NW 70TH AVE

Ph: 786-401-1138

AUTHORIZATION FORM

Month/Year