NOBILIS (IA sus - cP(//';r p( hit\ - ,---711,\\(///(//firir NOBILIS CREDIT CARD AUTHORIZATION Tel: Fax: Ship/Waive CFA: Hold for CFA Approval: Date: Nobilis Customer Number: Account Name: Pattern Number: Order Total: Ship to: sm: Quantity: VISA MASTERCARD AMERICAN EXPRESS Credit Card if: Expiration Date: / Name on Credit Card: Billing Address of card: Zip Code required: SIGNATURE: 3006 EMRICK BOULEVARD • BETHLEHEM, PA 18020 • (610) 866-8320 • FAX: (610) 866-8322 EFTA00558755