LZ KRIVO bate: 12 «kes As the Indi required. As the com| required. Amount Credit Card Name as it RN GostizeKvogrod, ara evograd sp RAD Tok Wr pl avian fo cross ne oooe eer eae Goal beget ones ins Zt peta Bee tamiaeee cies eae setts Credit Card Authorization Form Ae ge 204 9 J Wivokovor: - Hiworr dog ies Qrove\us Printed Name idual cardholder, | hereby authorize this card to be used for the deposit any representative, | hereby authorize this card to be used for the deposit 452,80€ information: ppears on the Card: Liktinm Nivalovse, CoV IY Type of Card: VISA XX. MASTERCARD Credit Card Expiration Number5255- Atak -shto 4550 ateOt 7 21 Security Code BACK of Visa OR Master Card: (3 digits) _ 5.54 Credit Card xg city: © Country:_ Cardholder o1 Signature:_| filling Address: Street: igosiay Kereza ho 6F sooceepe pyc fpCode: 000 Telephone: 2910 Gostigée Krivograd Poljana 10 a, 2391 Prevalfe, Slovenia Tel: (+386) 2 82 40 690, Email: info@krivograd.si, www krivograd.si