EFTA00525153.pdf

CUMSTOPUER HYLAND INCORPORATED CREDIT CARD AUTHORIZATION FORM Invoice #(s): Company Name. Cardholder Name C.0 Billing Address: lelcphonc C-XeRtS-S 121-[55 (must list all invoice numbers here). it.rnAcis LL.c. JEFFREY E. EPS"El tit GI CAST Thst Moto& I °Ca Credit Card Type: Card Number: CC Verification Code Expiration Date: (found in signature area on back of card) 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 a Gas. dollars. 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(K I IRISTOPHERIIYLA ND.NET EFTA00525153