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(773) 276-2662
MJ@tileoutletchicago.com
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Contact Us
Phone Order Charge Authorization
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.
Phone Order Remote Charge Form
Please fill out the following form to authorize Tile Outlet Ltd to manually charge your credit card:
Today's Date
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Email
*
Phone Number
*
Card Type
*
Visa
Master Card
Discover Card
American Express
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
Phone
This field is for validation purposes and should be left unchanged.