EFTA00522360.pdf

Memorial Sloan-Kettering Cancer Center The Bobst International Center 160 East 53rd Street, I Floor New York, NY 10022 Credit Card Payment Authorization Office Facsimile Office Telephone By signing below, I hereby authorize the Memorial Sloan-Kettering to charge my Credit Card for any physician visits, procedures, and tests, treatment modalities and/or services that may be provided to me at Memorial Sloan-Kettering Cancer Center. We will require approval for each charge to the credit card. Patient Account Number_35367668 Patient Name (Last, First)_ Payer Zip Code 10021 Payer Relationship to Patient friend Payment Amount Indicate type ofcredit card to be charged (We do not accept Debit Cards) Z American Express ❑ Mastercard ❑ Visa ❑ Diners Club ❑ Discover Credit Card Number Exp. Date 05/16 CVN 9129 'Cardholder's Information: (The Address where the credit card statements are mailed) Signature Street 9E 71" St. City New York, NY Country USA PostalCode 10021 Telephone # Date 12/28/12 Credit Card Authorization may be faxed to The Bobst International Center at Please call to say you have faxed this form. Payment Authorization Form Credit Card (revised 11/9110) EFTA00522360