EFTA00616676.pdf

Client: New York Strategy Physical Address: 457 Madison Ave New Yoh, NY 10022 Dab Management Inc. 3322 West Loop 366 San Angeio, TX 76904 CREDIT CARD AUTHORIZAT ION Please print cut this form, fi ll out completely, and retur n fax to Data Manageme nt st Company I -3Clnive-s 1-C I Credt Cam, Bing Address: Carchcider Name: L ctpFgey tEsmai Phone Number. Pleaseforward hie form to my eon repre sefrative proelPtly. Pooreseetative name ] eireM , give Data Management Inc permission to char ge the amount of SI 105420, for this purchase (includng any shipping and taxes) to the cred it card below. Please keep this credit card number and aulhorlz.aticn on 'Ile for any future purchase s. (Check one) Yes Please consider this single form b be authorization for at future purchase s. CINo. I vAll fill out an autiodzabon form each tine I make a creditcard purchase. Please check one: VISA MASTERCARD!: AMERICAN EXPRESSO DISCOVERD Credit Card Number: piraion Date: Q Name on Credit Card: a — Sign z atur y e: Date: 7171 x/07 TUT demandis enefiefeedialand Aga wee he eir *toted, pebtitlend to,eftseine4, fa ',Ade es Ar pert,”Ohne pie: waste perentesien of Dern moneirptete, pee. The tem: end many Mein CPI! silbfrcr to change withnot rake. EFTA00616676