Town & Country Cleaners

Pickup and Delivery Service Form

Added Bonus: Once your service begins, refer a friend or family member using this form, and receive a special gift with the beginning of their service.

New Customer Existing Customer

Name:

Billing Address:

Pickup Location:

Home
Work

Pickup Address:
(if different)

Home Phone:

Work Phone:

Starch Preference:

None	Light
Medium	Heavy

Permission to Email Coupons / Info? Yes No

E-Mail Address:

Payment Method:

Check Credit Card

A Credit Card must be on file for all charge accounts. Automatic billing may be selected as payment method. Charges not paid by the 15th of the month will be charged to the Credit Card on file.

By submitting this form, I understand that the total amount due for services rendered is payable by the 10th of every month. I also understand that if payment is not received by the 10th of each month, a $5.00 late fee will be added to my account. If my account is not paid by the 15th of the month, then my Credit Card may be charged the entire balance due at that time. I understand and agree to these terms. I am responsible for all charges to my account. I understand that an itemized bill is available upon request for any monthly invoice.

After submitting this form, you will be contacted by our office to add a Credit Card to your customer file.

Please click "Register!" only once.