LA SIESTA INC

3325 NW 70TH AVE

Miami, FL 33122
Ph: 786-401-1138
Fax: 786-401-1139

CREDIT CARD
AUTHORIZATION FORM
COMPANY NAME:
CARDHOLDER INFORMATION
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Address:
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CREDIT CARD INFORMATION

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Expiration Date
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INVOICE INFORMATION
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Total authorized charges

Authorized Signature: