Advance Spine Care and Pain Management

2555 E. Colorado Blvd. #306

Pasadena, CA 91107

Purchase Approved

August 10^th, 2015                                                                                                                                            3:23 pm

Order #:                                                                                                                                                               14395645456

Amount                                                                                                                                                                $10.00

X ____________________________________________________________________

  John Smith (Cardholder Name)

The cardholder acknowledges receipt of goods and/or services in the amount of the total shown hereon and agrees to perform the obligations set forth in the cardholder’s agreement with the issuer.

___________________________________________________________________________________________________________________________________________

Transaction Details:

Transaction ID:                                 211324234323

Approval Code:                                 054564G

Card Number:                                    **** **** 4343

Card Type:                                          Visa

AVS Response:                                  Y

CVV2 Response:                               M

Response:                                           Approved