Todays Date: ___/____/____

Type Item Amount

Sale ____________________________ $

Amount to be charged to Credit Card $

"Note: All Sales Are Final"

Credit Card Authorization:

Card Type: Visa Mastercard American Express Discover

Card Number: ________________________________ Expiration Date: ____/_____

I agree to abide by cardholder agreement conditions

Authorized Signature: X________________________________ Date:____/____/____

Card Billing Address Verification:

Name: __________________________________

Street: __________________________________

City, ST, Zip: __________________________________

Please fax back the completed form to: Alan Pre-Fab Building Corp, Attn: Bill Andrus Fax 310 538 0436