EFTA00525209.pdf

DataSet-9 1 page 67 words document

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📄 Extracted Text (67 words)

ducduc.

                          CREDIT CARD AUTHORIZATION FORM

    PLEASE PRINT OUT AND COMPLETE THIS AUTHORIZATION AND RETURN IT TO OUR OFFICE BY FAX: (212) 226-5504

CLIENT NAME:

Cardholder Name:                                     Signature:

Address:

Credit Card Type:
           AMEX                   VISA              MASTERCARD           DISCOVER

Credit Card Number:

Expiration Date:

Billing Zip Code:

Card Identification Number (last 3 digits located on the back of the credit card):

                                  Card
           0000111122223333"999   Identification
                                  Number

  VISA

Amount Charged: $                                  (USD)

                                                                                          EFTA00525209

ℹ️ Document Details

SHA-256

13abc1bd535db99ed9831e69fb330ece987f449a7582a2eb74c561dc1e7cb8b1

Bates Number

EFTA00525209

Dataset

DataSet-9

Document Type

document

Pages

1

Comments 0

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