EFTA00186536



211-107 MIDSbc (11/10)


# COMMERCIAL CARD PRODUCTS – INDIVIDUAL ACCOUNT INFORMATION

## SECTION I - AUTHORIZED USERS

**Name**

- Michael D. Friedman
- Mothers Maiden Name (Optional)

**Company Name:** NES LLC
**Company Number:** Company Number:

| Cardholder billing address | City | State | ZIP Code |
| :--- | :--- | :--- | :--- |
| Special Handling Instruction: Federal Express | City | State | ZIP Code |
| Plastic address if different from Cardholder billing address: | | | |
| Mothers Maiden Name (Optional) | Social Security Number (Optional) | Home telephone # (Optional) | Account Number (Metavance Use) |
| Cardholder billing address | City | State | ZIP Code |
| Special handling instruction: Federal Express | City | State | ZIP Code |
| Plastic address if different from Cardholder billing address: | | | |
| **Name** | Credit Line | Cash Advance Capability "D" or % of Limit Pin Y/N | Reporting Unit (Optional) Dept, ID Dept, Name | General Ledger # Assigned * Taxable Y/N* | MEA Y/N* |
| Mothers Maiden Name (Optional) | Social Security Number (Optional) | Home telephone # (Optional) | Account Number (Metavance Use) |
| Cardholder billing address | City | State | ZIP Code |
| Special handling instructions: Federal Express | City | State | ZIP Code |
| Plastic address if different from Cardholder billing address: | | | |
| Mothers Maiden Name (Optional) | Social Security Number (Optional) | Home telephone # (Optional) | Account Number (Metavance Use) |

*Visa Purchasing Card Option*
Financial Institution Name: [Insert Financial Institution Name]
Authorized Signature: [Insert Authorized Signature]