6301 Prairie Drive, Fort Smith, AR 72916 Phone (479)452-1199 Fax (479)452-2538

Name as it appears on the card: ________________________________________________________________

Billing Address:___________________________________________________________

Store Name:_____________________________________________________________

Credit Card (check one): ___ Amex   ___Visa   ___ MC   ___Discover

Credit Card Number:_______________________________________________________

Expiration Date:__________________________________________________________

   TO BE USED FOR (check one or more)

    ONE PURCHASE            AS NEEED                PAY WEEKLY           PAY STATEMENT

   ONLY WHEN CALLED BY CARDHOLDER

Authorized people who can charge to this card:

Name: Signature: ____________________________________________________________

Name: Signature: ____________________________________________________________

Name: Signature: ____________________________________________________________

 BY SIGNING BELOW, THE CARDHOLDER LISTED ABOVE AUTHORIZES RIVER VALLEY FLORAL 

 DISTRIBUTORS TO MAKE CHARGES TO THE LISTED CARD PER THE INSTRUCTIONS ABOVE. 

 THE CARDHOLDER AGREES THAT THESES INSTRUCTIONS WILL REMAIN VALID UNTIL 

 AUTHORIZATION IS REVOKED BY THE CARDHOLDER IN WRITING.

Cardholder Signature:______________________________________________________                                                      

 Date:________________

 To PRINT off a Copy of this file.