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?

- Month - Day Year

Name *

First Name Last Name

Phone Number *

- Area Code Phone Number

E-mail *

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

PICK-UP/DROP-OFF

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer

Daytime Phone

- Area Code Phone Number

Daytime Phone Extension #

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

Cleaning Preferences

Shirts *

On Hanger Folded/Boxed

Starch *

Heavy Medium Light None

Where will the cloths be left to pick up? *

Where should the cloths be left when delivered? *

Special Circumstances (Check all that apply)

Sprinkler Dog Alarm Gate Housekeeper Other

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 *

Visa Mastercard AMEX Discover

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 *

Clear