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ALL APPLICANTS - Billing Information
Type of Account:
HOME/OFFICE DELIVERY - ADDRESS
Leave clothes at:
OK to leave if no one's home? :
If raining? :
HOME/OFFICE DELIVERY - PREFERENCES
Name on Card:
Credit Card Type:
SPECIAL REQUESTS AND COMMENTS
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