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~ <br /> . - <br /> - redrt Card Payment P~~~~~'` ~ ~ ~ <br /> Revised: 03/04 } <br /> Please fax this form to this fax ~.5~~~~"~ ' Thank out <br /> Y <br /> Today's Date: 1 1 /7/2008 Your name: Eric R Jones <br /> Business Name: Eugene Public Works Customer <br /> Address: 858 Pearl St., Eugene, OR 97401 <br /> Agency Name: Eugene Public Works Agency <br /> Card Type: ~ Visa 0 MC AmEx ~ Discover <br /> .5~-~.~ ~.~-3 i ~'~i~7 ~~7.~ <br /> Lard Number: <br /> i <br /> ~ Expiration Date: Aug-08 <br /> J Cardholder Name: Eric R ones <br /> i <br /> 1 <br /> Invoice # or Prepayment Month Amount Paid <br /> Eugene Leaf Program Commercial Production November $575.Op <br /> Eugene Leaf Program Commercial Schedule ~ November $925.00 <br /> i <br /> i <br /> i <br /> i <br /> Cardholder Signature: ~ Total Charge: $1,500.00 <br /> <br /> i, <br /> Mail Receipt to: Eric Jones, Eu ene Public Works; 858 Pearl St , Eu ene, OR 97401 <br /> OR: <br /> Fax Receipt To: Fax Number: <br /> Your Phone.#: 541-682-5523 <br /> ccount~ng se n ~ <br /> onfirmation Number:. <br /> ransaction Date:. <br /> rocessed By: <br /> <br />