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Phone Order Charge Authorization
This form is for customers who are completing a
transaction only. Please call the store to place your order prior to filling out this form.
Phone Order Remote Charge Form
Please fill out the following form to authorize Tile Outlet Ltd to manually charge your credit card:
MM slash DD slash YYYY
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 Authorize the Following Person to Use My Credit Card Information (if applicable)
Enter Person's Name and Relation to You [i.e. Designer, Personal Shopper, Relative, etc.]
I hereby authorize Tile Outlet Ltd. to charge the aforementioned credit card in the agreed upon amount listed herein.
Agree to Transaction
This field is for validation purposes and should be left unchanged.