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10 2~1 North Rd
1029 North Rd
Wrstf1P.ld, M,1 1~~ .., ( liu :..,• t h n i ons ~Ji' 11 Westfield. Massachusetts 01085-s? 11

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Ser vices Se rv1 c: es

MA De~)ar1 !rn~nt or MA - Depamnent 0 1 S4t:i 00
Dt::velopmt•: 1tdl ~ c•rv1,' es Dt:velopmenta i Serv ices
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Sut>l ot11I $ 4~) (lU ::3t1ofutcil

Total: $46.00 Total: $46 .00

Payment Payment
r; ,ernt C a ,cl 8 11u11 ,~ ,, , (t.; 70 7; Credit Card ending ,n (6?~7) ':,4 .:S uo
Amount Paid: $46.00 Amount Paid: $46 .00

Credit Card Author ization Credit Card AuthoriLation

Hy s1g111r,g I authorize IDE MIA ancl/01 tt ,e1, Gy s1g n1ng _I authorize IDE MIA ancl/or t r1e1r
age, 1t~ tu cndrg1:- rny credit carli for servicE: agents to ci-,arge my r,18d1t ,-:ard for service
(~) perform~d anU/or proc1 uct::i purcria sed I (s) periorrned and/or products purchased 1
agre~ that I will pdy for this purcha~e 1n agree that I will pay for this purct1ase in
accoraance with the 1ssuir1g bank accordance w1tn the issuing bank
c ardholder agreement carc.lhulder 2tgree!,1ent

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S1qnaturt S1gr1ature
 ld or ,t , ,r ,(; CA: r It o; 131 u0(J2 '.:JJ ldcntoGO C en ter /3 1O(JCiL~ .
1fi /~ ll o rth Rd 1028 Nort h Rd
W estfield 1-,fa •, •,, , r h u:,0 t 1·, G108~ 97 I 1 W estfi eld , Massa chu~ett ~ (,1085-~711
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Servic es Servr c.es
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Total : $46 .00 T otal : $ 46 .00
Payment Pa ym f: nt
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Amou nt Pa ;d : $4 6 .00 Am ount Pai d : $46 .00
Credit Card Authorization Credit Card Auth oriLation
By ~1gn1r1g I authorize IDEMIA an d/or the,, Jr· s:y n,ng I aua·,f;1 12e 1L1E M 1/, an-:lt(ir t r,E: 11
agent& to c narge rn\1 credrt card for S€1'\iice agents tu c:-, arG E- :11 1 r ,F.:Gr t ,· 2:11 .l fu1 service:
! ~) perfcrmed anc.J/or produc h-. purcn asea I (s) performed and/or products purc hasea
ag ree that I w di pay for !h rs purc h~~e 1,1 agree that I wi ll pay for th,~ pu r~ ~1ase ,n
accora ance wrtn the 1ssurr1g bank acco rdance:: w1tri the rssu,ng ban k
cardholder agreement carur1 e;lder 21 g ree: 11er it
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Total : $46 .00
Payment
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Am ount Paid: $46.00
Credit Card Author ization
Uy t. l(J11irro I aut11w11e IDI lv1 1Aa nd/ur tl ,e11
al~8rib, to nl1d 1g1: my 1,red 1t caru t,11 t1erv1c~
(~) pertrnmed a, 1d/ur prucluc lt, p111<,t 1~btJd I
au 1et: that I will pdy for t111 s purt-11at>e ,r,
al,(;ordance w1tll tt1~ 1bs u11 19 l)al 1k
car cit 1oldur aor~ernerit
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 ldcnt1 GO Cante, , 31 GOG.:'.) 1
102S North Rd
W estfiel d Massa c husett s 0 108 5 -9 7 1 1

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Services
MA · Depart1 m:nt Of '3 4:=i lJl1
Ot=,1elopm e:-1tal S 2 rv11~t-:,
(DDS)

Sub1 otal Sti5 no

Total : $46.00

Payme nt
Crernt Card end111g 1n (o797J $:\5 00

Amou nt Paid : $46.00

Credit Card Autho riz.atio n

By s1gn1rig I aut11on ze IDEM IA ancl/or the11
agents to charge 1ny credit card for servicE:
(s) performed and/or product::. r.,iurcr1ased I
agree that I will pdy for this purcl1a~e in
accordance vv1tn the 1ssurng bank
cardho lder agreement

S1~natu rt