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 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
Name on Account:
Address on Account:
MillIMIIMIMIf
.9 L' ?id fitee
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