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 ________________________________________
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