EFTA00523289.pdf

kravet Inc KRAVET LEE JOFA BRUNSCHWIG & FILS GP&J BAKER Payment Authorization Form Date: Account Name: Account #: Business Phone: Mobile Phone: Email: Comments/Special Instructions Payment Information ®Card Type: Choose One Name on Card: Credit Card #CI 1 Security Code: Expiration Date: i Billing Zip Code: Total to Charge: $ OCheck Payment (Complete Below) Bank Name: Check#: Banking Account #: Routing #: Check Total: $ Customer Signature Approval & Authorization I authorize the verification of the information provided & permission to charge to my credit/debit card for agreed upon purchases/payments. I understand that my full credit card information is not stored by Kravet Inc. or its subsidiaries but is tokenized to eliminate risk of a security breach. NOTICE TO U.S. CUSTOMER ABOUT ELECTRONIC CHECK CONVERSION: When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution. ** DO NOT MAIL YOUR PHYSICAL CHECK TO US*** Signature: Date: Kravet Inc. i 225 Central Ave S. Bethpage NY 11714 I I Fax: Please Save this form and submit to EFTA00523289