.s.1A
-.3.c.
CliinisrrotPrikat Ilvtaxi) IscconirstwitAnt)
CREDIT CARD AUTHORIZATION FORM
Invoice #(s): / WG (must list all invoice numbers here).
Company Name: tr- tec
Cardholder Name: Fc/q L y & ps 7 ei /NJ
C.C. Billing Address: 96 7/ Si
/ 11 e Von 14" ) t( Zio Code: / (-) /
Telephone:
Credit Card Type: /1.4 X
Card Number:
CC Verification Code: (found in signature area on back of card)
Expiration Date:
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( f rpce >get ei talf A` a et14-7Y dollars.
(S 7 , 9 yo . oo )
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