DS9 Document EFTA00520926

.s.1A -.3.c. CliinisrrotPrikat Ilvtaxi) IscconirstwitAnt) CREDIT CARD AUTHORIZATION FORM Invoice #(s): / WG Company Name: Cardholder Name: C.C. Billing Address: Telephone: tr- tec (must list all invoice numbers here). Fc/q L y & ps 7 ei /NJ 96 7/ Si / 11 e Credit Card Type: Card Number: CC Verification Code: Expiration Date: Von /1.4 X 14") t( Zio Code: / (-) / (found in signature area on back of card) I authorize Christopher Hyland, Inc. to charge my credit card number indicated above in the amount of (this must be written out in longhand): Se Ve /I 7 A-o ce Jane( frpce >get ei talf A` a et14-7Y dollars. (S 7 , 9 yo . o o ) I AM FULLY AWARE THAT CHRISTOPHER HYLAND, INC. DOES NOT ACCEPT RETURNS OR EXCHANGES AND THAT ALL SALES ARE FINAL. MY SIGNATURE HEREIN BELOW CONFIRMS MY ACCEPTANCE OF ALL THAT IS STATED ABOVE. Cardholder Signature: D & D BUILDING SUITE 1710 979 THIRD AVENUE NEW YORK, NEW YORK 10022 TELEPHONE EFTA00520926