New Client

My Account Information  
   
Your Personal Details * Required information
Gender:   Mr.     Mrs.     Ms. *
First Name: *
Last Name:  *
E-Mail Address:  *
Company Name:  
Telephone Number: *
Cell Number: *
 
Pick up & Delivery Address
Street Address:  *
City:  *
State/Province:  *
Zip Code:  *
 
Payment
Credit Card:  *
Credit Card Owner:  *
Credit Card Number:  *
Credit Card Expiry Date:  *
I authorize Alex's Drycleaning to charge my credit card for services provided.
     I hereby certify that the information in this application is true and correct.
 
Credit Card Billing Address
(for verification and security purposes)
Street Address:  *
City:  *
State:  *
Zip:  *
 
Route Service
Select:  *
Pick-Up Location:  *
 
Cleaning Instruction
Laundered Shirts:  *
Starch:  *
Special Instructions:
 
Referral Source
How did you
hear about us:		  
Please specify  

If you need to schedule your first pick up after you submit this form,
please click on the free pick up link.