Credit Card Authorization Form

Credit Card Authorization Form Type of Card Visa L2 Master Card i American Express Account Number Expnration Date 06/21 Security Code 9049 Name on the Card Jeffrey Epstein Company Name Billing Address 9 East 71st Street New York, NY 10021 Phone Number E-mail By signing this form. you authorize TAKARA BELMONT USA, Inc to charge your card for the amount of listed SALES ORDER Signed Jefffrey Epstein Date Nov. 23, 2018 By security reason, we will discard this form after charged your amount for this order. Therefore, TAKARA BELMONT USA.Inc will never possess your credit card's information. EFTA00313950