EFTA00313837.pdf

RADIO Loa -v. ASSOCIATES (KEY)-026372663051-1RACtIOLOGY 1176 FIFTH AVE 1ST FLOOR 026546464530, NW 10017 RI -IONIC: 21 2-241 -6381 Name: JEFFREY EPSTEIN Card Number: >00000000000001" Card Ekn Data: >C></>CX Card Not Present Transaction Type: AMEX SALE Merchant 10: 9334822 Transaction Amount: $50.00 ^tin, Code: 161404 Ticket tt: 87170621 Invoice tit: 720691'3 [Date: 11/15/13 11:14:41 AM CAFt0IVIEMBEFt ACKNOWLEDGES rxeceurrr OF GOODS "NJO/OFt SERVICES IN THE AMOUNT OF THE TOTAL SHOWN HEREIN ANJO AGREES TO PERFORM THE OBLIGATIONS SET FORTH BY THE CAIROMEIVIESEFt's AGREEMENT WITH ISSUER SIGNATURE CUSTOMER COPY Mount Sinai Radiology Associates Date: 15 14/1Dv OiLc) 01- 02225 1176 Fifth Avenue, Box 1235 New York, NY 10029-6475 212-241-6381 1. Rr eived from: £PSin $ ars25 tb+DVY) tannQ l datient: ,0 ((1 0;(\ e mrst: tigklle tO6Qi3 I DOS: DH ft .4. DO LS Amt. of Accoun (2) CC Amt. Paid Cash Balance Due /o Check # Operators Signatur EFTA00313837