EFTA00314142.pdf

ts Send to: G3 C;lobal Services. Attn: Passport Department 388 Market street. Sudo 1520 San Francine:0. CAA 94111 fit/8981203 I SanHancir.roco3vC.:c: cool YCcr SECOND VALID PASSPORT SAN FRANCISCO be Srt 10 istAir ccitacl email • Check here' you require a hard copy incILIded ',tat your return teiweri Payment Information I :Payment Via Chock D Ix: I ,ayrtiont Via Credit Card: yisarpAasal card: 54 74. I S13-7308-9256 x Ooncierqe Service Requested Exp. Date. 11 / 19 Security Code: 3 5 7 OR American Express: e :w.r! App:!cable, ! Page Exp. Date: / Security Code: Name as it appears on the card: FEE # Travelers TOTAL Darren K. Indyke Concierge Fee $175.00 X = $175.00 US Government Fee Si 7o.00 x $170.00 Billing Address: 575 Lexington Ave. 4th Floor G3 Service Fee $275.00 X = $275.00 bay NY State NY Zip: 10022 Passport Protection Pto $40.00 X = $40.00 Return Deivery Fee $5.00 Signature. Subtotal 58565.00 Add 5% for credit card conversance fee $37.20 Ap;.,rovc;! ! • • l• G3 CuStomer Number, Billets. P.O.. Project or Reference Codes: Total Payment Enclosed $70220 Traveler Information Traveler 1 Name: Jeffrey Edward Epstein Dated BAT 01/20/1953 Tamar 2 Name Date of Birth: Passport Service Service: x Seccod Wad Passport (Rook Only) Processing Speed: x hessian Critical Primly Dmedded Second Said Passport (Book and Card) Travel Details Date of US Departure ANTICIPATED 06/_/2016 I must have my passport no laW than: 06/ /2016 Other visa or passport sernces requested: Notes: Contact Information Name: Darren K. Indyke Company: Darren K. Indyke, PLLC Creed Entail (required): Daytime Phone " i/ePha Return Delivery Address Wne: Darren K. Indyke Company: Darren K. Indyke, PLLC Street Address-. 575 Loxington, 4th Floor State: NY t eitf Now York Zip Code: imp Daytime Phone. Mobile Phone: EFTA00314142