TOP HAT UNIFORM INC.
dba TOP HAT IMAGEWEAR
230 DUFFY AVENUE — SUITE E
HICKSVILLE NY 11801
TEL:
FAX:
EMAIL:
CREDIT CARD FORM
Customer Name:
Address: 9 z=-Of Wx/ ,f6-ez`/ /1/2/(o',2/
Credit Card (circle one): Visa Mastercard
Credit Card #:
Exp. Date: I' 7 V Code: 766e9
Name on Account: PIIIIMMW__
71 S Z1 „r/ret if46,/ 03,/, Ny 7o.tf
Address on Account: .9 Fad 74 ,,
Amount to be charged: S
J 6 <.,L
Apply to Invoice/Sales Order or Purchase Order #
Authorized by: , 7?• ,7a.
EFTA00520749