8077 San Fernando Road, Sun Valley CA 91352 Tel: (818) 252-6426 Fax: (818) 252-7086

CUSTOMER CREDIT CARD AUTHORIZATION FORM

I, ______________________________, the authorized cardholder hereby give full authorization to Tony Shoes, Inc. to charge my credit card below for the order(s) placed by myself with your company.

Billing information:

Name (as it appears on the card) --------------------------------------------------------------------------

Billing Address: --------------------------------------------------------------------------------------

City, State, Zip ---------------------------------------------------------------------------------------

Shipping information (if different from billing)

Business Name --------------------------------------------------------------------------------------

Address ----------------------------------------------------------------------------------------------

City, State, Zip --------------------------------------------------------------------------------------

Telephone -------------------------------------

Fax ---------------------------------------------

Credit Card # --------------------------------

4/3 digit V-code -----------------------------

Expiration Date ------------------------------

Cardholder’s Signature -------------------------------- Date ------------------------------

NOTE: IF THIS CREDIT CARD IS TO BE KEPT ON FILE AND USED FOR FUTURE ORDERS, PLEASE SIGN BELOW:

Signature ------------------------------------------- Date: -----------------------------------

Please submit order by: Fax: (818) 252-7086

or e-mail to info@tonyshoesinc.com

or mail to: Tony Shoes, Inc.

8077 San Fernando Rd.

Sun Valley, CA 91352