EFTA00520749.pdf

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`/ / /(o',2/ /12 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