EFTA01221343.pdf

We Strive for Excellence in Sales and Service Steve Landis Sales Manager 4180 S. University Drive • Davie, Florida 33328 F CREDIT CARD AUTHORIZATION FORM Date: .5 IF INDICATED, THIS FOR A ONE-TIME CHARGE OF S 3, g 97:00 I HEREBY AUTHORIZE BURKIIARD'S TRACTOR & EQUIPMENT INC. TO CHARGE MY: VISA / MASTERCARD / DISCOVER /AMERICAN EXPRESS) Cardmember's Name: ANN M 14-disc ~z Company Name: STF, LAC Phone Number: 390 — 77.5-A25AS Account It: j Expiration Date O / ao CV2 Info 7 0O 9 Month / Year 3 digits on the right side-back of card Cardmember's Billing Address: 9E 7/.54. SFREE+ Nuo yvk, ny/0602/ Shipping Address: (Ifhems are to be shipped, Please note shipping charges will apply) 50-E, Si-.7hOMAS TR0pk AI Sh; pp; AM q 505 N. vilts-MOVI Avg. /vticYPA 33178' Cardmember's Signiture •r PLEASE FAX/ EMAIL THIS FORM, WITH A PHOTOCOPY OF BOTH THE rflONT cS, BACK OF THE CREDIT CARD, AND A PHOTOCOPY OF PICTURE IDENTIFICATION TO: 954-475—0465 OR [email protected] **Please be advised if this form is not filled out completely and the requested documents attached, we will not be able to process your order. Thank you! ** EFTA01221343  PASSPORT PASSEPORT Zaltirieik IMMO irk& PrACCO0 ' PASAPORTE Tyco/ Tin/ 'Suwon \ 14a ROORtUEZ Own agres/Preerntrilliitn7 Ilyouhiy l umevaie.i,nxwwdw UNITED STATES ;OF.: Ag4E RICA i0e Nonni. it4saliqifitck St( /Sue /taw IlirAlmeI lassii de nxintiento ItCANDE• U.S. VIRGIN AI Putt ily I Altai* /Aitord,d ow el ince/ on WmItoI Etc ha de ape:60Rn ....7 7. /Iry e"pcluutlad 'Department of.State."'I •—• < :(towtavids/LieeticnIsitwestAralciort; 111K5.613W SEE PAGE 27. . Nhel it EFTA01221344