<strong\><tt\>SILVERLININGETC.com</tt></strong>
<strong\><tt\>Wicker furniture & Gifts</tt></strong>
<strong\><tt\>12 New Dorp Lane</tt></strong>
<strong\><tt\>Staten Island, N.Y. 10306</tt></strong>
<strong\><tt\>Fax &Phone 718-968 9626</tt></strong>

Name and address of credit card holder.

First Name           Last Name

Street Address  City & State

Zip Code                           Phone Number

E-Mail Address

Visa                 Expiration date

Master             Expiration date

Amex               Expiration date

Discover           Expiration date

FOR SPECIAL COMMENTS OR DELIVERY INSTRUCTIONS PLEASE FILL OUT BOX BELOW.

TO EDIT THIS FORM AFTER SUBMITTING, CLICK BACK TO FORM ON CONFIRMATION PAGE.