EFTA00314070.pdf

ROCCO MITI NOTE LS CREDIT CARD AUTHORISATION FORM Cornauxerme o6 mime Please complete and fax the form to floacanyfima. aa nonnate ;la Have $opmy n crrnpaabTe ee no $axc Or alternatively email to the following dedicated email address HJIH OTII IlbTe tia arIeKT HH 10 110tiT I will be responsible for charges to the value of / A paspew alo [mere c MOC* Kama cramy a pasmepe : nbOO PI.-6 (Wee event/EAHHoopeme . .H0 O monody Ammo:Jig.) 0 Annually /EaceroAlio El othermpyroe 0 Please specifyiflowanyacra, nonourre I wish the charges incurred on the above account(s) to be settled in the following manner: paapemaio npottanecru murnte umfeaumm cpeo-ra cuettYmutuu o6pa3oM: Credit Card Type: Teri xpectersoCi Miner Amete.% ett ra R Q. elciS Credit Card Number: First Four Digits Last Four Digits HOsiep meatisioir amnia: Dept** wereipe tuitfm6/31 -4(O19-1 ClocneAwe .4ereipe 414P. }q it 1O lit Credit Card Expiry Date: IC3Ma ReActtarreabna go: OCelea D 2.I Issue Number (for Maestro only): Homer, seinycica: (TO/lake An Kap Maestro) Start date (for Maestro only): Kapra Aekrtaireribira c: (Mabee rsne Kapp Maestro) „e ------`-...„.. Card Holder Signature: floAnmce AePwarene xarrns: Name (in capitals): OHO (nemaisibatst 6yeaatast)• ED MEIDEEKlEEMELOODEI Date/Aara: Statement Address for Credit Card / Avec nfroatiillamma q EAST t1-(ST StrzaS--• e viV 1 4//egg, N/ joi0a). Contact Telephone N umber / Hoserairmai rene$on Proof of card holder's identification may be required with this form (Passport) / K Aannoll Sopme mower nowe6osarbot ninvuntarrt,Immo uottym orra. Yllocrosepsiomero Aliquot-re, Aepacarenu (nacnoPT) Credit Card Expiry Date / Kapn Aerscrebrrenetia Ocelaoa-I EFTA00314070