te 1//1-li K JCB 0 Discover Credit Card a lErAmer K VS MasterCard Diners Billing Address q G-Ast 1r-- g-rieGar City E tj x to State N .! zipIOO?} Country Lt s A Telephone Fax Email Amount $ .5-0 j) 0 • Approval Codes Item purchased [also, state quantity]: I assume respo ibility for