EKULO DISTRIBUTION COMPANY, USA, INC. 14900 HILTON DRIVE FONTANA, CA 92336-4026 Tel: (909) 823-5675   Fax: (909) 823-5099 E-mail: ekulocs@ekulousa.com

Credit Card Authorization

Date: ________________

Customer Name:  ______________________________________________________________

Credit Card Billing Address:   ____________________________________________________
           
                                                   ____________________________________________________

City:        ____________________________________ State:  ____ Zip:  __________________

Please indicate which credit card to charge:             Total Amount:  $__________________
           

____ American Express
____Discover
____MasterCard
____Visa

This is the 3-digit number on the back
of your Credit Card.   For American Express, use
the 4-digit number on the front of the Card.

______________________________________________________________________________
CARDHOLDER’S NAME AS IT APPEARS ON CARD     (PLEASE PRINT)

______________________________________________________________________________
CARDHOLDER’S SIGNATURE

I authorize EKULO DISTRIBUTION CO, USA, INC., to charge my credit/debit card as indicated above, and I will have this credit card authorization as my receipt for this transaction.

PLEASE FAX BACK PROMPTLY TO: (909) 823-5099