Credit Card Holder's Authorization:
credit card number
in the amount of $ -916 6 ‘ for a purchase order agreement.
Security Code 03 digits on back of card I Amex 4 digits on front of card)
PO:
• NO CREDIT CARD CAN BE
DATE: PROCESSED WITHOUT A COPY
OF DRIVER'S LICENSE AND
Deposit CREDIT CARD FRONT I BACK
Payment in Full
Balance
By signing below, I acknowledge the charges described hereon. Payment in full
to be made when billed or in extends payment in accordance with standard
policy of issuing card Company.
Billing Address: 9 E. 726/ 11/2 -ae
New yeti/ fr/ /was/
17651 Biscayne Blvd. Aventura, FL 33160 I Phone I Fax
EFTA00520750