GEORGE V EATERTAINMENT S.A.
NYE 2014
DEBIT AUTHORIZATION
ADDRESSER :
SENDER : MELLE SONIA NEBACH
SOCIETY :
DAY :
TELECOPIE & ADDRESSE E-MAIL :
ADDRESSE E-MAIL :
accueil@buddhabar.com
PHONE :
TELECOPIE :
+ 33 1 53 05 90 09
RE :
PHONE :
+ 33 1 53 05 90 00
 URGENT
 REMARK
 REPLY
 CONFIDENTIAL
PLEASE ATTACH WITH THIS FORM A COPY ON BOTH SIDES OF YOUR
CREDIT CARD
Hereby, I
Living in
Authorize the Restaurant BUDDHA-BAR to charge my credit card, and forward the
following references:
CB /
VISA CARD /
MASTER CARD /
AMERICAN EXPRESS
N°
Expiry Date:
N° Crypto (security code) :
To the sum of
€uros
Date and Signature:
(1) Please delete as appropriate
(1)