CUMSTOPUER HYLAND INCORPORATED
CREDIT CARD AUTHORIZATION FORM
Invoice #(s): 121-[55 (must list all invoice numbers here).
Company Name. it.rnAcis LL.c.
Cardholder Name JEFFREY E. EPS"El tit
C.0 Billing Address: GI CAST Thst
Moto& I °Ca
lelcphonc
Credit Card Type: C-XeRtS-S
Card Number:
CC Verification Code (found in signature area on back of card)
Expiration Date: 2_0
I authorize Christopher Hyland. Ire. to charge my credit card number indicated above in
the amount of (this must be written out in longhand):
Six RUHNKeNlimakrh-- - N E dollars.
a Gas. )
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 OFFLL THAT IS STATED ABOVE.
Cardholder Signature:
Date: ID
0 & D BUILDING SUITE 1710 979 THIRD AVENUE NEW YORK. NEW YORK 10022
TELEPHONE (212) 688-6121 FAX (212)6084176 EMAIL: INFO(KI IRISTOPHERIIYLA ND.NET
EFTA00525153