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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
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.
The cardholder acknowledges that Cintas is contracted to provide a scheduled service to the Cardholder's Company or
Policy #R-5207
Exhibit A
Page 2 of 2
Corporate Purchasing Card
Customer Registration Form