CaringPeople Credit Card Authorization Form 0 • \N Client Name TERJE ROD LARSON ( Name on Card Card Number Address 0 Amex 0 Visa 0 Mastercard 0

Insured's Name: TERJE ROD LARSON Please Address Inquiries to: Caring People 118-35 QUEENS BLVD. 1st Floor Forest Hills, NY 11375 Call: 00 - CaringPeople Invoice No: 245243 0 ALWAYS COSINICTFO - Ls! 'Wein NI.‘$.(1 & Fl. *** COPY *** Client Original Invoice Invoice Date: 05/02/2018 Service Date