Phone Order Charge Authorization

Today's Date*

Name*

First Last

Email*

Phone Number*

Card Type*

Last 4 Digits of Credit Card*

Verification Code on Back of Card*

Amount to be Charged*

Please fill in the total amount to be charged.

Invoice/Purchase Order Number*

Please enter the invoice/purchase order given at time of phone order.

I hereby authorize Tile Outlet Ltd. to charge the aforementioned credit card in the agreed upon amount listed herein.*

Phone

This field is for validation purposes and should be left unchanged.

This form is for customers who are completing a phone order transaction only. Please call the store to place your order prior to filling out this form.