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<br />,""19"15/" No. 0214890
<br />. ~ {(. -- '1:'1 f ...5 () 0;: - 0 I.~' WORK TICKET NO. 53'598/
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<br />x:!/ ~ t/ STATEI7~ ZIP CODE
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<br />ACCT. NO,
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<br />SOLD TO
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<br />ADDRESS
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<br />CITY
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<br />CASH. . . . . . . . 0 0 0 CHARGE, EXISTING ACCOUNT .-ir" C--?
<br />SALE AMOUNT. . . . . . , . , . , . , , . , . . . , . . BilL, NEXT Bill 0 R ~ CHARGE, NEW ACCOUNT...AUTHORIZErY.LL/~/C. / -
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<br />DOWN PAYMENT.. .REQ AMI. PD. A,') (J .-- CUSTOMER DESIRED MONTHLY PAYMENT AMOUNT .t';/~ --
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<br />QUANTITY STOCK ACCT, STORE COST AMOUNT OF SALE
<br /> NO. n ITEMS NO. ACCT. UNIJ
<br />ISSUED REro NET NO. UNIi tOTAL PRICE tOtAl
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<br /> SUMMARY OF STORES ACCOUNTS SUB TOTAL IA.\>j l~'C)
<br /> GEN,lED STORES
<br /> NO. ACCT, NO, ITEM AMOUNT
<br /> STATE TAX .~/ Yv'
<br /> EXCISE TAX
<br /> CITY TAX
<br /> -.;z: 1'1
<br /> TOTAL ,,)..2
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<br />SUMMARY OF REVENUE ACCOUNTS
<br />
<br />GlN.lED ITEM ITEM TAXES ASSESSED EXEMPT CODE
<br />NO. AMOUNT STATE EXCISE CITY OTHER S X C 0
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<br />TOTALS
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<br />CUSTOMER SIGNATURE nfJ~'-.Eli;
<br />INO.UDUAU PIIOVISlONS ON _ __ sa OF C1A'~COP'f.
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<br />ORIGINAl COPY
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