Credit Card Authorization Form
Type of Card Visa L2 Master Card i American Express
Account Number
Expnration 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 TAKARA BELMONT USA, Inc
to charge your card for the amount of listed SALES ORDER
Signed Jefffrey Epstein Date Nov. 23, 2018
By security reason, we will discard this form after charged your amount for this order.
Therefore, TAKARA BELMONT USA.Inc will never possess your credit card's information.
EFTA00313950