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. Post with this slip to PO Box 288. Rundle Mall. SA 5000 Details of fine MCPIR-15-1036/1 55609070044 11011111111111111101 01111111 Card type K Visa 0 MasterCard Name on card Card number Card expiry CCV _ Signature Date Amount $ EFTA00266556 www.flnes.sa.gow Breakdown of amount you

me Accession 10/14/20157:30 AM EDT MRLSPNI MOSKOWITZ, BRUCE W, M.D 6784742 PAYMENT IS DUE AT THE TIME OF SERVICE K Cash K Check K Mastercard K Visa K Amex K Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: £LLbh£LZLZ 643etal

end their credit card number via this third party form. CARDHOLDER INFORMATION - Required Name as it appears on the credit/debit card: Card Type: K Visa K MC Account Type: K Individual - K Debit / K Credit K Corporate - Company Name: Issuing Bank: Phone: Account Number: Exp. Date: Address

05 For information or to RSVP. please contact Kim DiTomasso a Of Jennifer Frost at 202.285.0966 or rji I would prefer to make a contribution by: K Visa j Me“ti‘eid J Atucnman LAplef$ Name as it appears on credit card CO: Exp. Signature EFTA00306114 Contributions or gifts to Nita Lowey fo

ry Cities to be visited and name of the respective hotel or cruise ship Payment Information Credit Card type : K Master Card Credit Card Number K Visa K American Express K Discover Card Expiry date (mm/dd/yyyy) Name on the Credit Card Signature EFTA00310367 Consulate General of Russia in Hou

on Employer Joint Contributor Occupation Joint Contributor Employer CREDIT CARD REPLY Please charge my contribution of $ to my credit card. K Visa K MasterCard K AMEX K Discover Account Number Expiration Date Name on Card Signature Mail to: Romney Victory, Inc. do Fifi Knott •190 Eliza

Accession 06/05/2018 8:30 AM EDT MRCLAVL MOSKOWITZ, BRUCE W, M.0 7156124 PAYMENT IS DUE AT THE TIME OF SERVICE 0 Cash 0 Check 0 Mastercard K Visa 0 Amex 0 Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: goon/noon WI xv O

ship to Patient friend Payment Amount Indicate type of credit card to be charged (We do not accept Debit Cards) Z American Express K Mastercard K Visa K Diners Club K Discover Credit Card Number Exp. Date 05/16 CVN 9129 'Cardholder's Information: (The Address where the credit card statements

are non returnable and non refundable. Stock orders may be returned in perfect condition within 30 days of delivery date with 25% restocking fee. K Visa Card No. K Master Card Expiration Date: VIN No. I agree to pay the above amount according to the card issuer agreement. Signature: Da

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7417 nvoice Date: 04/29/2011 Account 617185 Amount Due: $850.00 PAYABLE IN US FUNDS Pay by: K Check/Money Order K Discover o MasterCard 138 K Visa CI American Express Card Number Name on the card Expiration date Signature Please detach and return with payment rhit —rtittor EXIIITRE CONTRO

and/or company above as you wish it to appear in the printed program) NAME COMPANY ADDRESS CITY STATE ZIP E-MAIL PHONE FAX PLEASE CHARGE MY K Visa K MasterCard K American Express CARD NUMBER EXP. DATE CARDHOLDER SIGNATURE TOTAL $ Please make checks payable to Dubin Breast Center: (Tax-ID#

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