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CREDIT CARD AUTHORIZATION FORM <br />We Accept: Visa, MasterCard, and American Express <br />Date <br />By signing this form you confirm you are an authorized agent to commit on your <br />company's behalf and therefore you are authorizing Cross Match Technologies, Inc. <br />to charge your company's credit card for this amount in addition to any applicable <br />sales tax. <br />If your company is a tax exempt entity please provide your tax exemption certificate. ti A <br />Company Name: <br />Invoice/SO #: <br />Amount Authorized: $ <br />Credit Card Number; <br />Expiration Date: Sec Code: <br />Credit Card Complete Billing Address: <br />Please email receipt to: <br />Signature: <br />Printed Name: <br />Title <br />Date: <br />3950 RCA Blvd. Suite 5001 Palm Beach Gardens, FL 33410 PHONE 561.622.1650 FAX 561.828.7717 www.crossmatch.com <br />MP REV / 08-13-2012 <br />