Credit Card Authorization Form

Fax to: 614.430.9804

Card Holder Name

_________________________________________________________

Card Holder Email #

_________________________________________________________

Phone # :

_________________________________________________________

Fax Number:

_________________________________________________________

Delivery address:

_________________________________________________________

Delivery city/state/zip

_________________________________________________________

Cardholder's Name (as it appears on card):

_________________________________________________________

Credit Card billing address:

_________________________________________________________

Credit Card City/State/Zip

_________________________________________________________

I do authorize La Jeune Mariee to charge my credit card number:

Credit Card#:

_______________________________________Exp Date_____________

Security Code:

___________ (on the back of card, 3 digits Visa/MC/Disc and 4 digits AMEX)

In the amount of USD $_____________ for the Purchase Deposit and/or Balance that I have discussed with La Jeune Mariee.

I have been advised of all deposits & Payments are non-refundable & all sales are final by terms of this agreement. I take full responsibility for the above mentioned charges.

Signature: __________________________________ Date: ______________