EFTA00591418.pdf

EXECUTIVE OFFICES C• N. ANDREWS AVE. EXT. ‘P• POMPANO BEACH, FL 33064 IN FLORIDA Credit Card Authorization Form 1, , hereby authorize Mesmen inc. to charge my credit card in the amount not to exceed: S OS, bq ()Q VISA ( ) MasterCard ( ) American Express ( ) Discover Credit Card Number: - Expiration Date: C5 I / Credit Card Billing Address: Street PO, 60.)c 1110 0 VID Code: Cc 7 City: v It) /ex< state: A/ y Zip Code: ./0/ 5-re - Country: CS"- Telephone Number: (211) 3)-7 - cy/oe Requested Shipping Address: street /g89 inmTfAi LuTiikX Kivu- 1•R el- v0 City: kivi RS- 64Aeli State: gi-OX/04- Zip Code: 33 Country: 1,1 6 Telephone Number: (5?"/ ) 52-767 As the credit card holder, I herby authorize receipt of goods & services at the shipping address above. Cardholder's Signature // °29 / O C/ Date As the credit card holder, I also authorize Mesmen Inc. to charge my credit card for further purchases verbally approved by me. AuthoriZation Date Until: / Initals Here: Your completion of this form helps us protect you, our valued customers, from credit card fraud. Mesmen Inc. will keep all information entered on this form strictly confidential. LAUNDRY EQUIPMENT DISTRIBUTORS SALES - PARTS - SERVICE EFTA00591418 MESMEN, INC. 3178 NO ANDREWS AVE EXT POMPANO BCII FL 33064-2115 Bill To LITTLE ST. JAMES ISLAND US VIRGIN ISLANDS Invoice Date Invoice N 1/1212009 40393 Ship To P.O. No. Terms Due Dato Rep Ship Date Ship Via FOB TERRA CHEM TO DE ARRANGED 1/12/2009 IIF I2/30:008 STORAGE MESMER. INC. Item Description Oty Rate Amount STORAGE FREIGHT STORAGE FEE PER MONTH PER PALLET (FRIST 30 DAYS FREE) DATE STARTED ail 9508 X 2 PALLETS INLAND FREIGIfT & HANDLING FROM MESMEN TO FREIGHT FORWARDER THIS BILL IS UP TO DATE AS OF li Pi iiii 6% FL SALES TAX 7 I 25.00 210.56 175,001 210.56I i • TERMS TO BE DETERMINED Total EFTA00591419