EFTA01181739.pdf

Original Receipt. Clerk: ADMIN MT SINAI ASSOCIATES SHIMONY GROUP (SWPT-012310011009-SHIMONY GROUP 485 MADISON AVE (ggr 51.1.10. PHONE: Name: JEFFREY • . dailat-eLThcirk.-a C Card Number: Card Exp Date: XX/XX Card Present Transaction Type: VISA SALE Transaction Amount: $1995.00 Auth Code: 05142D AVS Reply Ticket #: Date: 09/27/12 04:45:04 PM CARDMEMBER ACKNOWLEDGES RECEIPT OF GOODS AND/OR SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREIN AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CARDMEMBER's AGREEMENT WITH ISSUER SIGNATURE MERCHANT COPY EFTA01181739