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[Gors]

Upon notification by SAA through reasonable attempts &/or communication channels of the non-acceptance of
the original charge(s) for the purchase of the above-mentioned Ticket(s) made to the Purchasing Credit Card.

                                                                                                                                       1/25/2010        
Name & Signature of Purchasing Credit Card Holder / ???*                                                         Date

* ???

1. ???

2. The ??? of the document is ???

3. The ??? of the document ???

4. The ??? of the document is ???

For Official Use

This document is ??? and ??? by.

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