Please forward to
BRIGHTON PAVILION
94 Cumberland
Memphis, TN 38112
(901) 458-7476
(901) 458-0804 (fax)
CREDIT CARD CHARGE AUTHORIZATION
AND INFORMATION SHEET
NAME OF SHOP:
ORDER NO.:
TYPE OF CARD:		VISA	MASTERCARD			CVV2 #
			Please circle one
NAME ON CARD:
CARD NUMBER:
EXPIRATION DATE:
BILLING ADDRESS:
PHONE / FAX NO.:
SIGNATURE:
PRINT NAME:
BALANCE DUE ACCEPTED ON CREDIT CARD:
		YES			NO