EFTA00591418.pdf

EXECUTIVE OFFICES N. ANDREWS AVE. EXT. C• ‘P• POMPANO BEACH, FL 33064 IN FLORIDA Credit Card Authorization Form 1, , hereby authorize Mesmen inc. to charge my credit card in the amount not to exceed: S OS, bq ()Q VISA ( ) MasterCard ( ) American Express ( ) Discover Credit Card Number: - Expiration Date: C5 I / VID Code: Cc 7 Credit Card Billing Address: Street PO, 60.)c 1110 0 City: v It) /ex< state: A/ y Zip Code: ./0/ 5-re - Country: CS"- Telephone Number: (211) 3)-7 - cy/oe Requested Shipping Address: street /g89 inmTfAi LuTiikX Kivu- 1•R el- v0 City: kivi RS- 64Aeli State: gi-OX/04 - Zip Code: 33 Country: 1,1 6 Telephone Number: (5?"/ ) 52-767 As the credit card holder, I herby authorize receipt of goods & services at the shipping address above. // °29 / O C/ Cardholder's Signature Date As the credit card holder, I also authorize Mesmen Inc. to charge my credit card for further purchases verbally approved by me. AuthoriZation Date Until: / Initals Here: Your completion of this form helps us protect you, our valued customers, from credit card fraud. Mesmen Inc. will keep all information entered on this form strictly confidential. LAUNDRY EQUIPMENT DISTRIBUTORS SALES - PARTS - SERVICE EFTA00591418 MESMEN, INC. Invoice 3178 NO ANDREWS AVE EXT POMPANO BCII FL 33064-2115 Date Invoice N 1/1212009 40393 Bill To Ship To LITTLE ST. JAMES ISLAND US VIRGIN ISLANDS P.O. No. Terms Due Dato Rep Ship Date Ship Via FOB TERRA CHEM TO DE ARRANGED 1/12/2009 IIF I2/30:008 STORAGE MESMER. INC. Item Description Oty Rate Amount STORAGE STORAGE FEE PER MONTH PER PALLET (FRIST 30 7 25.00 175,001 DAYS FREE) DATE STARTED ail 9508 X 2 PALLETS FREIGHT INLAND FREIGIfT & HANDLING FROM MESMEN I 210.56 210.56I TO FREIGHT FORWARDER THIS BILL IS UP TO DATE AS OF li Pi iiii 6% FL SALES TAX i• TERMS TO BE DETERMINED Total EFTA00591419