Monthly Accounts

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ALL APPLICANTS - Billing Information

Type of Account:

Your Name:

Address:

City:

State:

Zip:

E-mail Address:

Daytime Phone:

Evening Phone:

FAX Number:

Cell Phone:

HOME/OFFICE DELIVERY - ADDRESS

Contact Name:

Address:

City:

State:

Zip:

Delivery Phone:

Alternate:

Leave clothes at:

OK to leave if no one's home? :

If raining? :

HOME/OFFICE DELIVERY - PREFERENCES

How often?

Laundry Preference:

Starch Preference:

Shirts:

PAYMENT INFORMATION

Payment Method:

Name on Card:

Credit Card Type:

Number:

Expiration:

Security Code:

SPECIAL REQUESTS AND COMMENTS

Note:

 

Customer Authorization and Release I understand that my orders will be automatically charged to my Visa/MC/Discover/American Express account each month. A copy of all charges will be attached to each order for my reference. I certify that the enclosed information is true and complete. I agree to pay my charges in full within 21 days of the statement date. If an action for collection is filed, I agree to pay all costs and attorney fees incurred.

 


Signature / Date:

Mail to A Carriage Regal Cleaner • 11803 Wilshire Blvd. • L.A. • CA • 90025 • Attn: Rhonda Green

Fax to 1-310-477-2848

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