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