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