Customer Name: TOP HAT UNIFORM INC. dba TOP HAT IMAGEWEAR 230 DUFFY AVENUE — SUITE E HICKSVILLE NY 11801 TEL: FAX: EMAIL: CREDIT CARD FORM Address: 9 z=-Of Wx/ ,f6-ez`/ /12/ /(o',2/ Credit Card (circle one): Visa Mastercard Credit Card #: Exp. Date: I' 7 Name on Account: PIIIIMMW__ Address on Account: .9 Fad 74 71 S Z1 „r/ret if46,/ 03,/, Ny 7o.tf ,, V Code: 766e9 Amount to be charged: S Apply to Invoice/Sales Order or Purchase Order # J 6 <.,L Authorized by: , 7?• ,7a. EFTA00520749