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O <br />Quote Number: 01.792806 <br />CREDIT CARD AUTHORIZATION FORM <br />By signing this form you confirm you are an authorized representative to make binding commitments on <br />behalf of your company/firm. <br />It is therefore by your signature below that you are authorizing Cross Match Technologies, Inc. to charge <br />the below credit card for the amount stated below in addition to any applicable tax. <br />If your company is a tax exempt entity, please provide your tax exemption certificate. <br />Company Name: k%y IVIS CAU.i Y <br />Invoice/SO #: A'Pig - qW— <br />Amount Authorized: USD$ 8 9 1 Lo - 8Q <br />Credit Card Type: bl Visa a Master Card OAmerican Express <br />Is this a Government wide Commercial Purchase Card? OYes ONo <br />Credit Card Number: <br />Expiration Date: <br />Sec Code: <br />Credit Card Complete Billing Address: IZ(2AA &S%3 (� <br />WyMPTArI M �� <br />t"lasemz&-)U3A g09alo <br />Signature:q— Date: <br />Printed Name &g(M, / <br />Title__ <br />Crossmatch 3950 RCA Blvd Suite 5001, Palm Beach Gardens, FL 33410 <br />http://www,crossmatch.com <br />