1. Name and address section:

Your Name (required)

Your Address (required)

Home Phone

Cell Phone (required)

Driver's License # (required)

SS # (required)

Employer (required)

Employer Address (required)

Work Phone (required)

2. Credit Card Info:

Please Check:
 Visa Mastercard

Visa (No Dashes):

Mastercard (No Dashes):

Card Expiration (Required):

Bank Name (Required):

Name on Card (Required):

3. Joint Account (Optional)

 Check here for a Joint Account

Name

Address

Home Phone

Cell Phone

Driver's License #

SS #

Employer

Employer Address

Work Phone

Terms: Statements are mailed during the first week of every month. Payment is due by the last day of the month you receive the bill. Past due balances including all finance charges, exceeding (30) days from the due date will be automatically charged to your Mastercard or Visa. It is the customer's responsibility to notify Village Cleaners of all address and/or telephone number changes. The customer is liable for all reasonable costs of collection. Returned checks will be charged a $20 service fee.

Finance Charges: Finance charges will be assessed on accounts that are not paid in full by the monthly due date. Past due balances are subject to a finance charge of 1.5% per month (18% per year).

Authorization: I have read the above terms set forth and authorize Village Cleaners to charge my Mastercard or Visa account in accordance with said terms.

Online Customer Signature (Required):

Name: Date:

Would you like to sign up for Automatic Monthly Credit Card Payment?

 Yes No

If Yes, Complete below:

Name: Date:

Enter additional comments in the space provided below:

Please tell us how to get in touch with you:

Name:

Email:

Telephone:

Fax:

 Please contact me as soon as possible regarding this matter.