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~ <br />CROSSMATCH'" -Quute Number: 01.l~2H06 <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,,:r t1Mi l-DU.uT'{ S*Ge-tt:r's 0t=f1c..G: <br />Invoice/SO#: A,P\9 ~ L\l¼ <br />Amount Authorized: USD$ 8 9 llo 80 · <br />' <br />Credit Card Type: '/'if! Visa O Master Card O American Express <br />Is this a Government wide Commercial Purchase Card? OYes ONo <br />Credit Card Number: <br />Sec Code: <br />Credit Card Complete BIi/ing Address: <br />Signature:~ <br />8ltf'-$Clf: VL,) @:.C,li A:S 1 ,IJ lr <br />l< irru:::/lc s t Pu u :c '{ <br />c::5D7 w l)MPIAr-lUM QD <br />£'v..£,1.JS~U\U.,..1 loA 9~',.Q.lo <br />oare.-f/-21; )or7 <br />Printed Name_,...,Sb.........,'?V~,Q__...__.R~n..n--='-=a:,_.Af..,.__Dl\~i __ <br />Title ¾t, <br />6 <br />Crossmatch 3950 RCA Blvd Suite 5001, Palm Beach Gardens, FL 33410 <br />http://www.crossmatch.com