Cynamon Bros. & Sons, Inc.

1051 East 49^th Street, Hialeah, Florida 33013

Dade: 305-688-6653 / Broward: 954-523-2011

Fax: 305-688-5635

Credit Card Authorization Form

Date:

To:

I __________________________, on behalf of __________________________ do

hereby authorize to accept the following Credit Card charge to the card # noted below as

payment for:                          

Invoice #:                                ________________________________                               

Amount:                                  ________________________________

Card Type:                              ________________________________

Cardholders Name:                ________________________________

Billing Address for Card:         ________________________________

                                                ________________________________

Phone number:                       ________________________________

Card Number:                         ________________________________

Expiration Date:                      ________________________________

CVV Number:                         ________________________________

Approved By:                                                                                           Print Name:

Website: www.cynamonbrothers.com

Email: cynmn@bellsouth.net