EFTA01221169.pdf

Nortrax, Inc. 3933 Martin Luther King Blvd NORM-X Remit Payment to: Nortrax, Inc. West Palm Beach, FL 33404 Lockbox #24765 Phone: 561.848.6618 24765 Network Place Fax: 561-848.7099 Chicago, IL 60673.1247 Invoice To Account No.: 124 Sales Order for Future Processing Cash Customer - West Palm Beach Order No.: 865238 45 a, 1-1-C- Date: 8125/2015 35E(E Ibailo WA/ Page: I of Ian lm &, h, FL 33910 Deliver To: Cash Customer - West Palm Beach L3T£, Li-c 35g-Eitstao WA/ PAPA 15tach, FL Mob Home Ph: 33q8.0 Ph: Work Ph: Supplied Back Order Part Part Bin List Net Extended Quantity Quantity Number Delwin Ion Weight Los Price Price Price Machine ID: 2.00 0 R65563 PIN FASTENER 0.08 15FHE5 5.80 5.80 $11.60 2.00 0 1202958 RETAINER 0.00 0.95 0.95 $1.90 2.00 0 1414913 NUT 0.02 141-GD1 2.16 2.16 $4.32 2.00 0 1185710 Boot 0.08 43.10 43.10 $86.20 1.00 0 T188976 ROD 0.52 68.29 60.29 $86.29 1.00 0 1164259 Rod 0.48 67.05 67.05 $87.05 2.00 0 1401774 NUT 0.02 168F141 0.72 0.72 $1.44 2.00 0 AT169087 BALL JOINT 0.40 1400A2 29.78 29.76 $59.52 3.00 0 241.17040 WASHER 0.02 13CGB4 0.72 0.72 $2.16 2.00 0 M68954 LOCK NUT 0.03 15t3G03 1.47 1.47 $2.94 1.00 0 AM130908 Control Valve 8.34 890.36 690.38 $690.38 Total Weight: 10.00 Returnable Parts subject to a 20% Restocking Fee - Please see your local Parts or Service manager for current Promotions, Customer PO No.: SHERIDON ELIZEE Delivery Note: Sub Total: $993.78 3101 #148298. AVAILABLE 2-3 DAYS NO Sales Tax: $0.00 Tax Exempt No.: FREIGHT COSTS. Total: $993.78 Salesperson: BRADLEY BARTLETT Deposit Received: $0.00 Balance Due: $993.78 EXCLUDES TAX EFTA01221169  plz return to Tammy Grant T .AK il 111111110111111111 Credit Card Authorization for New Customers To: Nortrax, Inc. Re: Credit Card Number (Required Information) Expiration Date 0) 1.20 (Required Information) CVV2# Required Information) 3.diglts on back o car (please check one only) / / VISA / / MasterCard / (4LEX Name on Card: A NA gaftripl4- (Required Information) (please print) Billing Address: i (Billing Zip Code Required Information) Billing Phone Number: As this is a telephone order, this fax authorizes Nortrax to charge the above numbered card in the amount of S 993.78 only. Signature: (Must match on card & signature on photo ID provided) Under provision of the USA Patriot Act, we are responsible for knowing the identity of any new customer. Please attach a copy of the cardholders photo ID AND the front and back of the credit card to be charged. "Nortrax may use different methods to verify the information, including, but not limited to, Dunn & Bradstreet reports, credit bureau reports, and government-sponsored information web sites." (For Internal Use Only) Invoice #: 65238' t, Photo ID Attached I...a"— Front & back of credit card attached Credit Card transactions are subject to verification with the credit card company prior to shipment of the parts; delays may occur pending verification of Information and delivery addresses. Regional credit manager approval and investigation required prior to shipment Nortrax Credit Card Form (New Customere)eenvinweeewoositewrwrneene-wawnt 8/26/2016 EFTA01221170  Wiffielt VI ) Sy if i v ft r, ,,,, Jr $\.,,Ifm,vic,\ PASSPORT e(te PASSEPORT pae:;c4i r — 4 , •••e-4-41 a tte 0t Patat PASAPORTE Tsveltypt itpa ColraettEdatte ." • — -. P USA e ,. strrsnon.)m;A:c :CIY, RODRIQUEZ tes%tot:a Dawn !lama / Paeans Ali'''. ANN MARIA ilactect:e,ad : 2,-- s -1-4:::• laanceutity I taatotraltlt : UNITED STATES OFl ftt,}0 AMERICA a TWO ,•,. ,I,) age°, Ili/Z.2M Sex :Doe D4ao . teunceDLuoat Ge racorttreo US. VIRGIN ISLAND S ket.:44/.C.tonte Ateceael i Cc eapttcato . het Date c tote I Date de 6N:aren,e, United-States - 06 Jan 2014-0ged'o;hgatacc7J de “LuCAX Department of State ogeornpu tion, 05 Jan 2024 mcces A O3konn,s, yairore SploYe; Anec SEE PAGE 27 ESS AMERICAN; EXPR C. EFTA01221171