CREDIT CARD AUTHORIZATION FORM: PLEASE PRINT AND FAX 001-954-894-2930

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THE ENG GROUP LLC

18851 NE 29TH AVENUE, SUITE 700, AVENTURA, FL 33180  |  TEL (954) 323.2024   FAX (954)  894.2930

 CREDIT CARD AUTHORIZATION FORM

(AUTORIZACION DE CARGO EN LA TARJETA DE CREDITO)

 I………………………………………………….HEREBY AUTHORIZE THE ENG GROUP LLC TO DEBIT MY CREDIT CARD IN THE AMOUNT OF______________US$

SIGNATURE_____________________________________________________ (CARD HOLDER / TARJETAMBIENTE))

PLEASE PROVIDE THE FOLLOWING INFORMATION / POR  FAVOR PROVEER LA SIGUENTE INFORMACION:

1.)  TYPE OF CREDIT CARD: VISA____ MASTERCARD____AMEX____

2.)  NAME EXACTLY AS IT APPEARS ON THE CARD (NOMBRE QUE APARECE EN LA TARJETA)

______________________________________________________________________________

3.)  NUMBER OF THE CREDIT CARD ACCOUNT:_________-_________-_________-________

4.)  EXPIRATION DATE ON CARD_____________ / __________

5.)  CARD IDENTIFICATION NUMBER (CID)______________

6.)  MEMBER'S MAILING ADDRESS ON CREDIT CARD BEING USED (DIRECCION DEL ESTADO DE CUENTA) _____________________________________________________________________________________

________________________________________________________________________________________

7.)  CARD MEMBER'S HOME PHONE NO.:_________-_____________________

8.)  PHOTO COPY OF CREDIT CARD (BOTH SIDES)

9.)  COPY OF CREDIT CARD STATEMENT TO VERIFY MAILING ADDRESS

10.)   PICTURE ID

PLEASE NOTE THAT FAILURE TO PROVIDE ANY OF THE INFORMATION LISTED ABOVE WILL STOP THE PROCESS OF THIS TRANSACTION.

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BUSINESS 954.323.2024 / MOBILE 954.778.8543

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