EFTA00520926.pdf

.s.1A -.3.c. CliinisrrotPrikat Ilvtaxi) IscconirstwitAnt) CREDIT CARD AUTHORIZATION FORM Invoice #(s): / WG (must list all invoice numbers here). Company Name: tr- tec Cardholder Name: Fc/q L y & ps 7 ei /NJ C.C. Billing Address: 96 7/ Si / 11 e Von 14" ) t( Zio Code: / (-) / Telephone: Credit Card Type: /1.4 X Card Number: CC Verification Code: (found in signature area on back of card) Expiration Date: I authorize Christopher Hyland, Inc. to charge my credit card number indicated above in the amount of (this must be written out in longhand): Se Ve /I 7 A-o ce Jane( f rpce >get ei talf A` a et14-7Y dollars. (S 7 , 9 yo . oo ) I AM FULLY AWARE THAT CHRISTOPHER HYLAND, INC. DOES NOT ACCEPT RETURNS OR EXCHANGES AND THAT ALL SALES ARE FINAL. MY SIGNATURE HEREIN BELOW CONFIRMS MY ACCEPTANCE OF ALL THAT IS STATED ABOVE. Cardholder Signature: D & D BUILDING SUITE 1710 979 THIRD AVENUE NEW YORK, NEW YORK 10022 TELEPHONE EFTA00520926