ing Address Account Number: Name: Address: Apt.iSuitel: City: State: Zip: Phone: ( Fax: ( Authorizing Signature: Wx."00'1,2,76,00IIEMIUI2 FEMOW M40:001 m404 EFTA00219854 Invoice No: 7-105-77081 Invotce Date: Dec 25. 2000 Account Number: Page 3 el 4 Payment Type Detail (Original) S