Street:

Street: 9 E 7717/ -17/ PUBLICIDE: 250 W 40th Street, 8th Fl New York, NY 10018 Fir/. I Publicide Official Credit Card Authorization Form 4 7//Ea to charge tht(credit card in advance for all Purchase Orders received. Type of Card: 0 VISA 0 MASTERCARD Ill AMEX 0 DISCOVER Credit Card Number: Expiration Date: hereby authorize Publicide, °EAR CVC Security Code': 02 6 .i 'For MasterCard, Visa and Discover this is the last three digits on the number on the back of the card. For American Express it is the four digits in the corner of the card on the front. Credit Card Billing Address Requested Shipping Address Street: 9 E W./ jf City: /Vetti 1/4 71-- / City. 4 /44774", -- State: NY Zip Code: /4 1A2 State: /O / Zip Code: teat/ Telephone: Telephone:__ Cardholder's Signature Date (9O/g Your completion of this authorization form helps us to protect you, from credit card fraud. All information entered on this form will be kept strictly confidential by our company. Please email completed forms to EFTA00523823