Credit Card Authorization Form

Credit Card Authorization Form Type of Card Visa — MasterCard s American Express Account Number Expriration 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 TAMARA BELMONT USA. Inc to charge your card for the amount of listed SALES ORDER. Signed J titre By security Therefore, TA stein Date Nov. 23, 2018 son, we will discard this form after charged your amount for this order. BELMONT USA_Inc will never possess your credit card's information EFTA00313951