EFTA00557252.pdf

DATE: 10/12/2012 REF. 23835/CA6 Mrs ❑ Miss ❑ Mr ❑ FAMILY NAME: KENSINGTON FIRST NAME: PASSPORT Nb: DATE OF BIRTH: SHIPPING ADDRESS: HONG KONG TEL. Nb: FAX Nb: EMAIL ADDRESS: I hereby give to HERMES SELLIER my authorization to charge my credit card for the amount of: (n/tans L 326 € (in k&n) Product description: Shoulder strap, in black box, with palladium hardware O AMERICAN EXPRESS (*) Nb Security Code (compulsory) : (4 figures right hand side — face of card) O J. C. B. Nb SIGNATURE: EXPIRY DATE (EUROCARD, MASTERCARD and VISA are not acceptedfor mall order) (*) FOR PAYMENT BY AMERICAN EXPRESS CARD WOULD YOU PLEASE CONTACT THE AMERICAN EXPRESS CENTER OF YOUR COUNTRY TO CONFIRM THE PURCHASE. => We would like to draw your attention to the fact that various duties may be claimed by your Customs authorities on arrival of the goods in your country. EFTA00557252