. I certify that I am the authorized signer of the credit/debit card listed above. Cardholder Name: (Printed) Cardholder Signature: r Date: SSAdaaae_ r-P-6 GPSTFirJ Please do no s nd a photocopy of the front or back of your credit card. 1212 NW 82" Avenue. Miami FL 331261 P : (305) 629 8755 /