CHRISTOPHER HYLAND INCORPORATED
CHRISTOPHER HYLAND INCORPORATED
CREDIT CARD AUTHORIZATION FORM
Invoice #(s): 14 G5,5 (must list all invoice numbers here).
Company Name:
Cardholder Name:
C.C. Billing Address:
Telephone: licrefAncs de-F-FgEy E . L-Pt-MEIKI
Kbtn) \fotzi ,Zin Code ( 002- 1
Credit Card Type: P11/WAICA1.1 2)1°KtSS
Card Number:
CC Verification Code: (found in signature area on back of card)
Expiration Date: 2-1 ZO
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 l-4-ukima,b E
6.05.181dollars.
) 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 OF ALL THAT IS STATED ABOVE.
Cardholder Signature:
Date: 1D zg
D & D BUILDING SUITE 1710 979 THIRD AVENUE NEW YORK. NEW YORK 10022
TELEPHONE FAX E-MAIL:
EFTA00521139