TOP HAT UNIFORM INC. dba TOP HAT IMAGEWEAR 230 DUFFY AVENUE — SUITE E HICKSVILLE, NY 11801 CREDIT CARD FORM Customer lll Address: g lan a sZ , VI, f Sheet , Ne Mork MY LL LOL 7 Credit Card (circle one): Visa Mastercard American Express Credit Card #: Exp. Date: OF L Lf V Code: FE64 Address on Account: G Last S715 a Stal, WM tte’ Soyk, VY 10087 Amount to be charged: $ VA - FO 4 Apply to Invoice/Sales Order or Purchase Order # of 6 YGL Authorized by: Karyna Suhink Lon ; EFTA00520749