Nortrax, Inc.

Nortrax, Inc. 3933 Martin Luther King Blvd West Palm Beach, FL 33404 Phone: 561.848.6618 Fax: 561-848.7099 Invoice To Account No.: 124 NORM-X Cash Customer - West Palm Beach 45 a, 1-1-C- 35E( E Ibailo WA/ Ian lm &, h, FL 33910 Deliver To: Cash Customer - West Palm Beach L3T£, Li-c 35g-Eitstao WA/ PAPA 15tach, FL 33q8.0 Home Ph: Mob Ph: Work Ph: Remit Payment to: Nortrax, Inc. Lockbox #24765 24765 Network Place Chicago, IL 60673.1247 Sales Order for Future Processing Order No.: 865238 Date: 8125/2015 Page: I of Supplied Back Order Part Quantity Quantity Number Part Delwin Ion Weight Bin Los List Price Net Price Extended Price Machine ID: 2.00 0 R65563 PIN FASTENER 0.08 15FHE5 5.80 5.80 $11.60 2.00 0 1202958 RETAINER 0.00 0.95 0.95 $1.90 2.00 0 1414913 NUT 0.02 141-GD1 2.16 2.16 $4.32 2.00 0 1185710 Boot 0.08 43.10 43.10 $86.20 1.00 0 T188976 ROD 0.52 68.29 60.29 $86.29 1.00 0 1164259 Rod 0.48 67.05 67.05 $87.05 2.00 0 1401774 NUT 0.02 168F141 0.72 0.72 $1.44 2.00 0 AT169087 BALL JOINT 0.40 1400A2 29.78 29.76 $59.52 3.00 0 241.17040 WASHER 0.02 13CGB4 0.72 0.72 $2.16 2.00 0 M68954 LOCK NUT 0.03 15t3G03 1.47 1.47 $2.94 1.00 0 AM130908 Control Valve 8.34 890.36 690.38 $690.38 Total Weight: 10.00 Returnable Parts subject to a 20% Restocking Fee - Please see your local Parts or Service manager for current Promotions, Customer PO No.: SHERIDON ELIZEE Delivery Note: Sub Total: $993.78 Tax Exempt No.: 3101 #148298. AVAILABLE 2-3 DAYS NO FREIGHT COSTS. Sales Tax: $0.00 Total: $993.78 Salesperson: BRADLEY BARTLETT Deposit Received: $0.00 Balance Due: $993.78 EXCLUDES TAX EFTA01221169 To: Nortrax, Inc. Re: Credit Card Number T .AK il 111111110111111111 plz return to Tammy Grant Credit Card Authorization for New Customers (Required Information) Expiration Date 0) 1.20 (Required Information) CVV2# Required Information) 3.diglts on back o car (please check one only) / / VISA Name on Card: Billing Address: i / / MasterCard / (4LEX A NA gaftripl4- (Required Information) Billing Phone Number: (Billing Zip Code Required Information) As this is a telephone order, this fax authorizes Nortrax to charge the above numbered card in the amount of S 993.78 only. Signature: (please print) (Must match on card & signature on photo ID provided) Under provision of the USA Patriot Act, we are responsible for knowing the identity of any new customer. Please attach a copy of the cardholders photo ID AND the front and back of the credit card to be charged. "Nortrax may use different methods to verify the information, including, but not limited to, Dunn & Bradstreet reports, credit bureau reports, and government-sponsored information web sites." Invoice #: 65238' (For Internal Use Only) t, Photo ID Attached I...a"— Front & back of credit card attached Credit Card transactions are subject to verification with the credit card company prior to shipment of the parts; delays may occur pending verification of Information and delivery addresses. Regional credit manager approval and investigation required prior to shipment Nortrax Credit Card Form (New Customere)eenvinweeewoositewrwrneene-wawnt 8/26/2016 EFTA01221170 PASSPORT Wiffielt VI ) Sy if i v ft r, ,,,, Jr $\.,,Ifm,vic,\ PASSEPORT PASAPORTE Tsveltypt itpa ColraettEdatte ." pae:;c4i r — 4 , •••e-4-41 a tte 0t Patate(te • — -. e P USA ,. strrsnon.)m;A:c :CIY, RODRIQUEZ Dawn !lama / Paeans %tot:ates Ali'''. ANN MARIA : 2,-- s -1-4:::• laanceutity I taatotraltlt : ilactect:e,ad UNITED STATES OF AMERICA ,•,. ,I,) age°, Ili/Z.2M l ftt,}0 a TWO . teunceDLuoat Ge racorttreo US. VIRGIN ISLANDS Date c tote I Date de 6N:aren,e, heti Cc eapttcato 06 Jan 2014- . ogeornpution,0ged'o;hgatacc7J de “LuCAX 05 Jan 2024 O3konn,s, yairore SploYe; Anecmcces SEE PAGE 27 Sex :Doe D4ao ket.:44/.C.tonte Ateceael United-States - Department of State A AMERICAN; EXPRESS C. EFTA01221171