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