EFTA00295223.pdf

GRANDIHYATT GRAND HYATT TOKYO BILLING AUTHORIZATION FORM I Jeffrey Epstein authorize Grand Hyatt Tokyo to charge: (print full name) ($sfl) alijfilmgc:Epvmt-c-Fs.‘,(Please initial) O .fillIfilitAtfit O All Charges O In, +/—ex$4, tit* o Rooms, Service Charge & Tax o All car transports from :to airports and train in Others (please specify) To the credit card listed below: t- " 41 Credit Card Type: American Express t-1`043 *An Credit Card Number: 765840014009 Expiration Date: Jeffrey E. Epstein Name on Credit Card: 81ng** 212 750 98957"n** Phone Number: Fax Number:646 350 0396 Z.14 Signature: X -t M. Billing Address of credit card holder: 9 East 71st Street, New York, NY 10021 El iligthtTif (Statement by mail not required) ❑ IFilfzt*2 ( Statement by mail required) aft* (-EdgfiMa3iii'S0VICSEA-FL‘. ) Receiver's address(Fill in only if different from above) gA.013€44 Guest Name: 26530566 and 26530862 Confirmation#: From (Arrival Date): Sept 22-26 AndtDepatuge OctDa1-5e): CR..A.otzt.iotr.a.kffitelt. Thi-m-otttfR/111-.Eitore&, ). thrsinm rerrtstlfcbztitz'oZtAi.121 AfRfa0flifflOggizrgl(,turit, zigl8L%tzt.fltfa 0)1f.. *All personal information is limited to hotel-related purposes and for no other use. By submitting this form and any supporting documents, I confirm that I have read and agreed to the use of the personal information I am giving you in accordance with your Global Privacy Policy for Guests, which is available at * Please attach a legible copy of the front & back of the credit card. *7 L.*" Ft — lz(Dm e- (n) ttSiB < Grand Hyatt Tokyo 6-10-3 Roppongi, Minato-ku, Tokyo 106-0032, Japan Phone: +81 3-4333-1234 FAX: 481 3-4333-(tingifi) EFTA00295223