ROCCO MITI

ROCCO MITI NOTE LS CREDIT CARD AUTHORISATION FORM Cornauxerme o6 mime Please complete and fax the form to floacanyfima. aa non nate ;la Have $opmy n crrnpaabTe ee no $axc Or alternatively email to the following dedicated email address HJIH OTII IlbTe tia arIeKT HH 10 110tiT I will be responsible for charges to the value of / A paspewalo [mere c MOC* Kama cramy a pasmepe : nbOO PI.-6 (Wee event/EAHHoopeme..H0 O monody Ammo:Jig.) 0 Annually /EaceroAlio El othermpyroe 0 Please specifyiflowanyacra, nonourre I wish the charges incurred on the above account(s) to be settled in the following manner: paapemaio npottanecru murnte umfeaumm cpeo-ra cuettYmutuu o6pa3oM: Credit Card Type: Teri xpectersoCi Miner Amete.% ett ra R Q. elciS Credit Card Number: HOsiep meatisioir amnia: First Four Digits 6/31 -4(O19-1 Dept** wereipe tuitfm Last Four Digits }q ClocneAwe .4ereipe 414P. it 1O lit Credit Card Expiry Date: IC3Ma ReActtarreabna go: OCe lea D 2. I Issue Number (for Maestro only): Homer, seinycica: (TO/lake An Kap Maestro) Start date (for Maestro only): Kapra Aekrtaireribira c: (Mabee rsne Kapp Maestro) „e------`-...„.. Card Holder Signature: floAnmce AePwarene xarrns: Name (in capitals): OHO (nemaisibatst 6yeaatast)• Date/Aara: ED MEIDEEKlEEMELOODEI Statement Address for Credit Card / Avec nfroatiillamma Contact Telephone N umber / Hoserairmai rene$on q EAST t1-(ST StrzaS--• e viV 1/4/egg, N/ joi0a). Proof of card holder's identification may be required with this form (Passport) / K Aannoll Sopme mower nowe6osarbot ninvuntarrt, Immo uottymorra. Yllocrosepsiomero Aliquot-re, Aepacarenu (nacnoPT) Credit Card Expiry Date / Kapn Aerscrebrrenetia Ocelaoa-I EFTA00314070