LloydsCleaners.com - Pickup/Delivery Signup Form

Lloyds Cleaners | Mr. Dry Cleaners

Customer Information
(All information is strictly for the use of billing for cleaning service.)

On or after what date would you like the pickup/delivery service to start?

MonthDayYear

Name

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

PICK-UP/DROP-OFF

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Employer

Daytime Phone

Area CodePhone Number

Daytime Phone Extension #

(Daytime phone used only if pland has questions regarding clothing)

Cleaning Preferences

Shirts

Starch

Where will the cloths be left to pick up?

Where should the cloths be left when delivered?

Special Circumstances (Check all that apply)

If Housekeeper, what days/times will they be there?

If other, please explain

Directions: please provide closest road or intersection

AUTO BILLING

Credit Card #

Credit Card Type

Credit Card Expiration Month/Year

By completing and submitting this online form, you agree to to authorize Lloyds Cleaners/Mr. Dry Cleaners to keep your credit card information on file and to bill you.

You also agree to notify Lloyds Cleaners/Mr. Dry Cleaners immediatly of any changes to either the expiration date or card number doe to loss, expiration, or your desire to have billing directed to a different card.

Signature