TOP HAT UNIFORM INC. dba TOP HAT IMAGEWEAR 230 DUFFY AVENUE - SUITE E HICKSVILLE, NY 11801 CREDIT CARD FORM Customer Name: Address: “i - SL SZ Sorel New Mork. Ve FOF Credit Card (circle one): Visa Mastercard Credit Card #: Exp. Date: 23 Z £3 V Code: LIOG9 Name on Account: Address on Account: G E w/, ct reel Amount to be charged: $ LALO. LO Apply to Invoice/Sales Order or Purchase Order # Fa 7 Y6 6 Authorized by: (a ZA Sheds Zi] Z EFTA00520753