Cardmember's Signiture We Strive for Excellence in Sales and Service Cardmember's Name: Company Name: Phone Number: Account It: j Expiration Date O / ao CV2 Info 7 0O 9 Month / Year 3 digits on the right side-back of card Steve Landis Sales Manager 4180 S. University Drive • Davie, Florida 33328 F CREDIT CARD AUTHORIZATION FORM Date: .5 IF INDICATED, THIS FOR A ONE-TIME CHARGE OF S 3, g 97:00 I HEREBY AUTHORIZE BURKIIARD'S TRACTOR & EQUIPMENT INC. TO CHARGE MY: VISA / MASTERCARD / DISCOVER /AMERICAN EXPRESS) ANN M 14-disc ~z STF, LAC 390 — 77.5-A25AS Cardmember's Billing Address: 9E 7/.54. SFREE+ Nuo yvk, ny/0602/ Shipping Address: (If hems are to be shipped, Please note shipping charges will apply) 50-E, Si-.7hOMAS TR0pk A I Sh; pp; AM q 505 N. vilts-MOVI Avg. /vticYPA 33178' • r PLEASE FAX/ EMAIL THIS FORM, WITH A PHOTOCOPY OF BOTH THE rflONT cS, BACK OF THE CREDIT CARD, AND A PHOTOCOPY OF PICTURE IDENTIFICATION TO: 954-475—0465 OR sales@burkhard.corn **Please be advised if this form is not filled out completely and the requested documents attached, we will not be able to process your order. Thank you! ** EFTA01221343 PASSPORT PASSEPORT PASAPORTE 111K5.613W Zaltirieik IM MO Tyco/ Tin/ 'Suwon \ 14a ROORtUEZ Own agres/Preerntrilliitn7 Ilyouhiy l umevaie.i,nxwwdw UNITED STATES ;OF: . Ag4ERICA it4saliqifitcki0e Nonni. IlirAlme I lassii de nxintiento U.S. VIRGIN ItCANDE• ow el ince/ on AI Wm Ito I Etc ha de ape:60Rn /Iry e"pcluutlad :(towtavids/LieeticnIsitwestAralciort; SEE PAGE 27. . irk& PrACCO0 ' St( /Sue /taw Putt ily I Altai* /Aitord,d .... 7 7. 'Department of.State."'I •—• < it Nhel EFTA01221344