EFTA00313620.pdf

GRANDIHYATT GRAND HYATT TOKYO BILLING AUTHORIZATION FORM I Jeffrey Epstein authorize Grand Hyatt Tokyo to charge: (print full name) (Ste) alliliPiitizEPEPtitt-FZI.%. Meese wheal etIltAt Charges SE o SSC .9.-raft.at O Rooms, Service Charge &Tax O Sittig lOITI4Dinqfptit O Others (please specify) To the credit card listed below: t —rsr, Credit Card Type: American Express t —Fit* an II Credit Card Number: Expiration Date: 06/21 71 Name on Credit Card: Jeffrey E. Epstein Zane* 77'2.0.X0 -4 Phone Number. Fax Number: Z116 Signature: craw Billing Address of credit card holder: 9 East 71° Street, New York, NY 10021 ❑ movit#1*** (Statement by mail not required) ❑ jimmattev( Statement by mail required) Aft% (11211INLA5**CO;P:21EATtO. Receiver's address(Fill in only if different from above) iggiitc0845VI Guest Name: _ Confirmations: 33675183 :rate From (Arrival Date): Feb. 3,2017 Until (Departure Date): Feb. 25,. 2017 trt-Clitillt6ztittletnettAi. • AMOOMMORIZI11.#1..."Cl*. ss.:"Plal.‘kt:llt6)Yefi. 7*-Aftte<tiato. MB personal information is limited to hotel-related purposes and for no other use. By submitting this form and documents, I confirm that I have read and agreed to the use of the personal Information I am at/summing gMng you in accordance with your Global Privacy Policy for Guns. which Is available at privacy.hvatt.com. • Please mach a legible copy of the front IL back of the credit card. EFTA00313620