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Date: <br />CRED IT CARD AU THO RIZATION FORM <br />We Accept: Visa, MasterCard, and American Express <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 .-/J /Jc <br />sales tax. <br />If your company is a tax exempt entity please provide your tax exemption certificate. -f'J 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: ___________ Date : __ _ <br />Printed Name:, _____________ _ <br />Title ----------- <br />3950 RCA Blvd. Suite 5001 Palm Beach Gardens, FL 33410 PHONE 561 .622.1650 FAX 561 .828 .7717 Www .crQS$malch ,com <br />MP REV / 08-13-2012 . _.