CREDIT CARD AUTHORIZATION FORM

I,____________________________ authorize Steven Marsili Sales to charge my credit card when purchasing

Your Name

Ellie Shoes for_________________________________________.

Company Name

Credit Card Number: _______________________________________________

Expiration Date: ______________________

Security Code: ______________________

Credit Card Billing Address:

____________________________________________

__________________City ________State __________Zip

Name as it appears on the card: _______________________________________________

______________________________________________________ ____________________

Card Holder Signature Date

Please also provide front & back copy of the credit card.

J Thank you!