EFTA00314144.pdf

GRAND HYATT GRAND HYATT TOKYO BILLING AUTHORIZATION FORM l Jeffrey Epstein authorize Grand Hyatt Tokyo to charge: (print full name) (Est) 0frlillPtiNr-Efleftl-PCF₹1‘. ( ❑ .failflitelln • All Charges O n. 1 .—EXP. &t O Rooms, Service Chair aa ❑ NSIlfrflOtriCORAN0118. All car Partworts from no room arc :an El Others (please specify; 21110../.. To the credit card listed below: t—" 41 Credit Card Type: American Express Credit Card Number:37676584M ficmina 4009 Expiration Date: 6/21 gstr Jeffrey E. Epstein Name on Credit Card: Number: 212 750 98957 - *mt 350 ortgg n 8tFgn Phone Fax Number:— ---- .111€ Signature: X C Billing Address of credit card holder: 9 East 71st Street, New York, NY 10021 ❑ Mlitati NE** (Statement by mail not required) O 14.1111atitil (Statement by mail required) Atilt adattThel5Ift0DOCIZAT(y.) Receiver's address(Fill in only if different from above) e * Guest • Name. Na m 2 •=530566 and 26530862 Confirmations: from (Anvil Date/ ,Sept 22-26 Aacipeclgl i -5 r O e): CrfgAl‘tctrlotcliAtIllfil*, ark-PASCONAII,Iftt6trntttl. ttt I:100 AtUIO*J ®831_AALXLt12, pracykiattoom I7211, Ittir5 rl O 01-7,4 INLET N. felsofctilY6ZON. 7t rrali personal's-Sonny-Jon is ',mired to hotel related purposes and for re Odle, ' use. By submitting fhb form and any FRPRorliri documents. I confirm that I nave read and aced to the 1. • information lam wins you k, accordance with a your Global Privacy Policy for Guns, watch is evadable a re Please attach a legible copy of the front & back of the credit card. • 0 L.', ti Ft — EC)= e — (NE) tisaLl<t::to. Grand Hyatt Tokyo 810-3 Roppongi. telinato-ba Tokyo 106-0032. Japan Phone:41 3-4333-1234 FAA +813-4333-(Mailin EFTA00314144