I 

First Name_________________________

Last Name_________________________

Home Address ______________________

__________________________________

City  _________________________

Zip Code  _________________________

Home Phone _______________________

(For our use only, in case we have a question about your cleaning)

*Place of Work _________________________

Work Phone__________________ Ext._____

Email  ______________________________

Credit Card-  Master Card  Visa  Discover  American Express 

Account Number________________________________

Expiration Date _____________CVV________________

  - Zip Code__________________

I authorize Express Valet Dry Cleaning Service to bill my credit/debit card for payment of dry cleaning and laundry services provided to me.

File Signature  ________________________________________