Policy #R-5207

Exhibit A
Revised: February 17, 2016
Corporate Purchasing Card
Customer Registration Form
Customer Low Tide Kava Bar
Name: Invoice Message:
(Text on Page
2) Y N

Customer 2902A Beach Blvd. S

Billing Leave Invoice with Delivery:
Address: Gulfport, FL 33707 Y N

Approved Contacts Only:

(List on Page 2) Y N
Customer SAME AS ABOVE
Delivery
Address:

Dept. Dept.
Name: Contact:
Type of Visa
Card:
Cardholder's Tucker Kasm
Name:
Card 4 7 4 1 6 5 9 9 8 9 9 6 5 1 1 5
Number:
Expiration 0 5 2 2
Date: /
Reference Number: Please Do NOT Include CVV/Security Code

Cardholder Authorization

Cardholder acknowledges that Cintas is contracted to provide a scheduled service to the Cardholder's Company or
organization and that at each scheduled service interval Cintas will present a copy of all charges incurred to the
Departmental Contact named above or his/her designated representative for review and signed approval. The
cardholder acknowledges that the above-mentioned review and approval constitute receipt of the service performed by
Cintas, and that Cintas is authorized to submit the amounts agreed to during the review to the credit card company
using the information provided on this form.

Cardholder’s Tucker Kasm Date: 01/19/2018

Signature:

Restricted Authorization -- Personal Signature Required

The cardholder acknowledges that Cintas is contracted to provide a scheduled service to the Cardholder's Company or

Please send to Secure Fax # 727-577-7096

Organization and that at each scheduled service interval Cintas will present a copy of all charges incurred to the
cardholder named above for his/her review and signed approval. The cardholder requires his/her signature on all
charges to constitute receipt of the service, and requests that no deliveries be made in his/her absence .

Cardholder’s Auto CC – Please Sign Above Date:

Signature:

Cintas Office Use:

Location Number: 069 Customer 11710 Contract Number:
Number:

Date Entered: By:

Policy #R-5207
Exhibit A
Page 2 of 2
Corporate Purchasing Card
Customer Registration Form

Invoice Message Text:

Approved Contacts List:

Sean Simpson, Tucker Kasm, Carl

Ricciardi

Please send to Secure Fax # 727-577-7096