KAIMUKI DRY GOODS 1144 10th Avenue Honolulu, HI 96816, USA (808) 734-2141

CHARGE AUTHORIZATION FORM

Please fill out all parts of this form and fax to (808) 735-9587, or mail to our address above. Mahalo! Note: Fill out areas using the exact information found on your credit card billing statement. TODAY'S DATE: ________________ FIRST NAME: _____________________________      M.I.: _________ LAST NAME: ______________________________      PHONE #: ___________________________________ ADDRESS: _______________________________________________________________________________ CITY: _____________________________      STATE: ________________      ZIP: ____________________ CARD TYPE: _____ MASTERCARD    _____ VISA CARD #: _____________________________________________      EXP. DATE: _______________________ SIGNATURE: ________________________________________________ FABRIC ORDER INFORMATION CATALOG OR PATTERN CATEGORY: _________________________________    ITEM NUMBER: __________________________________ YARDAGE / AMOUNT: _________________________________