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Credit Authorization

Please Use the Following Form to Submit Your Credit Authorization

Please enter company name.
Please enter contact name.
Please enter a telephone number
Please enter an email address
Please enter a shipping address
Please enter a shipping city/state/zip
Please enter cardholder's name
Please enter a valid card number
Please enter card expiration date
Please enter a valid security code
Please enter card billing address
Please enter card billing city/state/zip
Please enter the total merchandise amount
I hereby authorize the purchase of services/merchandise from Lafayette Textiles Corp. ("Lafayette") using this Credit Card Authorization Form. I agree that I will pay for this purchase and indemnify and hold Lafayette Textiles Corp. harmless against any liability pursuant to this authorization.

I understand that my signature on this form will serve as authorized signature on the credit card charge slip. I have read and agreed on Lafayette Textiles Corp.'s Terms and Conditions mentioned on its Order Confirmation/Work Order, Packing List, Invoice, Contract or other General Policy regarding sell of goods and services. The customer agrees and authorizes Lafayette Textiles Corp. to charge the customer's card from time to time based on Lafayette's Invoices to the Customer.

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2051 E 55th St., Los Angeles (323) 581 9220 info@lafayettetextile.com
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