After you fill out the form you may send it or print it to take it with you if you are planning to visit one of our stores in the next 3 days.

Email:	You can optionally print this form, click here.
Last Name MI First Name
Address
Country Zip
Home Phone Bus Ph Cell Ph
Company
Customer Options
Starch
Shirts: None Light Medium Heavy Pants: None Light Medium Heavy
FOP Payment :
We Accept
C.C# Exp. Date CVV2#
Billing Address City
State Zip Code
Name on the card
I hereby authorize X Clean Services, LLC to charge my credit card to pay for the services I have ordered in the conditions I have agreed. Date :
For a printer friendly version of this form click here.