co > K \) / POKP SHRISTOPHER HyLAND INCORPORATED CREDIT CARD AUTHORIZATION FORM Invoice #(s): HESS (must list all invoice numbers here). LIJE LC Company Name: Cardholder Name: JSE FERE (PLT EI C.C. Billing Address: GE Wl S#+ c Mew 1erK WY Zip Code. (2 © A_/ Telephone: —k——E Credit Card Type: A mex ad’u_e CC Verification Code: | (found in signature area on back of card) Expiration Date: | I authorize Christopher Hyland, Inc. to charge my credit card number indicated above in the amount of (this must be written out in longhand): Se Yen Thowesand Fecwe Aen cleod FOurTY dollars 1 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 OF ALL THAT IS STATED ABOVE. —z Cardholder Signature: a_i : Date: OT [ AS LIF D & D BUILDING SUITE 1710 979 THIRD AVENUE NEW YORK, NEW YORK 10022 TELEPHONE EFTA00520926