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Credit Card Holder's Authorization
August 12,2018
l i&F riwy p hereby authorize
Arta facto to charge my credit card as follows:
• Visa Master Card \-/ Amex
• Number: j
• Expiration Date:
• Security code:
• In the amount of: $ 20, O e
Reggae "6,ss.:ee cieros CM? ezeira/a/rted Ze p ceitc-44SeC
IMPORTANT NOTE: PLEASE ATTACH A COPY OF YOUR DRIVER'S LICENSE.
By signing below, I acknowledge the charges described here on. Payment in full
to be made when billed or in extended payment in accordance with standard
policy of issuing card Company.
Name as it Appears on Card: Jet=r-R C',Y
kr-
S 76 / 11-1
Billing Address: .9 E 7/S t
City: Metal yo
State:
Zip: 00
Signature Date
17651 Biscayne Blvd Aventurn Fl 11I AO
Phone:
EFTA00524155