Credit Cart Charge Slip

The following information is necessary in order to process your credit card.

User Name:______________________(This is for Mohawk to identify you.)

Name:_____________________________________________
          (Exactly how it appears on credit Card)

Type of Card and Number:

☐ VISA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

☐ M/C __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

☐ AMEX __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration Date: __ /__

Security Code: ___________ (Located on Back of MC and Visa and on the Front of AMEX.)

Credit Card Billing Address:

Street:________________________

Town:________________________

State: ________________________

Zip: _________________________

Signature:_______________________________________________________