B&B FURNITURE GROUP, INC.

I ______________________________, do hereby authorize B&B Furniture Group, Inc. to charge my credit card in full for the following quote, sales order, or invoice number(s).

 

Invoice # ____________________                       Amount ____________________

 

Invoice # ____________________                       Amount ____________________

 

Invoice # ____________________                       Amount ____________________

Please fill out the following information in order to charge your credit card:

Account Name: ______________________________________________________________________________________________

 

Type of Card (Visa, Amex, Etc.) ____________________________________

 

Name as it appears on card: ________________________________________________________________________________

 

Card # ____________________________________________________________

 

Expiration Date: __________________________

 

V Code (3 or 4 digit code on back of card): _________________________

 

Billing address for card (including zip code): 

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

 

Signature: __________________________________________________________             Date: __________________________

 

Print Name: ________________________________________________________