Credit Card Authorization Form @ American Express Type of Card © Visa Master Card Expriration Date 06/21 Security Code Name onthe Card Jeffrey Epstein 9049 Company Name New York, NY 10021 ena By signing this form, you authorize TAKARA BELMONT USA, Inc to charge your card for the amount of listed SALES ORDER. Signed Jefffrey £pstein j C i By security reason, we will discard this form after charged your amount for this order Therefore, TAKARA BELMONT USA, Inc will never possess your credit card's information EFTA00313951