Thanks, Jason! The address on that order form, 7th and Chestnut Streets in Philadelphia, is right next door to the second location of Corson's store, Collector's Haven, as given in his ad in the August 1, 1948 Card Collector's Bulletin. Actually, since it was a basement store, it might have even been in the basement of the same building. I showed this image in my long post on Corson, linked above.
That's further good evidence, if any was needed, that this ACC originally belonged to Corson. I love historical detective work like this!