Customer Name: Address: TOP HAT UNIFORM INC. dba TOP HAT IMAGEWEAR 230 DUFFY AVENUE — SUITE E HICKSVILLE. NY 11801 TEL: FAX: EMAIL CREDIT CARD FORM 9 F at / Neefi Xoyi,407 /00.21 Credit Card (circle one): Visa Mastercard Credit Card #: Exp. Date: ay.t.3 V Code: 0/96 29 MillIMIIMIMI Name on Account: Address on Account: .9 L' ?id fitee f Amount to be charged: S teo. Op Apply to Invoice/Sales Order or Purchase Order # 4:U 7 l7 Authorized by: /at „ SAA% Z EFTA00520753