TOP HAT UNIFORM INC.
dba TOP HAT IMAGEVVEAR
230 DUFFY AVENUE - SUITE E
HICKSVILLE, NY 11801
TEL:
FAX:
EMAIL:
CREDIT CARD FORM
Customer Name:
Address:
Credit Card (circle one): Visa Mastercard American Express
Credit Card #:
Exp. Date: V Code:
Name on Account:
Address on Account:
Amount to be charged: $
Apply to Invoice/Sales Order or Purchase Order #
Authorized by:
EFTA00521106