Gulfstream Aerospace Corporation

Gulfstream Aerospace Corporation Credit Card Transaction Authorization Form Date: Customer Name: Customer Number: Customer Contact Name: Customer Contact Phone No.: Customer Contact Fax Number: Company Name on Credit Card: Individual Name on Credit Card: Credit Card Billing Address: (must match address on fik with CC company) Type of Credit Card: Credit Card Number: Credit Card Expiration Date: HYPERION AIR, INC. CH200 LARRY VISOSKI 3 or 4 Digit Security Code* *American Express must have security code to process* Total Amount Authorized to Charge: $_ 12,319.36 Invoices or Other References / Amounts to be paid (must list singularly): Invoice NoJ Reference Amount Invoice No./ Reference Amount 1 8 2 9 3 10 4 11 5 12 6 13 7 14 We acknowledge that all parts returned are subjec to restocking fees and shipping charges. By my signature, I certify that I am authorized to execute this transaction and that I agree to pay in full all charges related to the above transaction(s). Signature Print Name & Title Card Name Verification Batch .! Approval (Gulfstream Use Only) EFTA01093390