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- - <br /> . <br /> ~ e ~ QTY. CLA D CftIPT103V PRICE A OtI~N~T <br /> _ d <br /> r 0 <br /> a U <br /> ~ <br /> J ~ <br /> 1. i DATE AUTHORIZATION TOTAL y ~ <br /> t/~YIf'I~ SERVER ,TAX V <br /> ? ID-FOLIO/CHECK NOJLIC. NO. STATE REGJDEPT. CLERK TIP <br /> MISC. <br /> SIGN ffiERE ~ ~ ~ ~ ' <br /> <br /> X ~ ` ~ ~ ~ 1~ i <br /> The Issuer of the card IdenRRed on thle Rem Isauftwdzed to pa the amount etwvm ae TOTAL CUSTOMER' RETAIN THIS COPY FOR YOUR RECORDS <br /> uponP~rpreeentatlon. i promise to pay such"TOTAL (together wtth any other charges due ~ ~ ~ <br /> thereon) aub)ectto ens In accordance wflh the egreementgoveminq the use of ouch card. <br /> ~ ' <br /> hf€~ <br /> Rece1pt for Mo <br /> nthiy LUnchepn <br /> ~ o <br /> date <br /> d <br /> <br />