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IMLS - Customer Information Sheet

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Client Information Sheet IM Laundry Services

Note: All personal information is held securely in accordance with the appropriate legislation, is confidential and treated appropriately.

Date

______________________________________

Client Information

First Name _________________________________

Middle Name _________________________________

Last Name _________________________________

Nick Name _________________________________

Complete Address
_______________________________________________________________________

Telephone Numbers/Contact Details

Home ___________________________ Work ______________________________________

Cellphone ___________________________

Email/s __________________________________________________________________________

Employment Information

Occupation __________________________________________________________________________

Employer Name ____________________________________________________________________

Personal Information

Date of Birth ___________________________ Marital Status ________________________________

Signature _______________________________

For IM Laundry Services Use Only

Date Encoded: ______________________________

Encoded By: ______________________________

Verified By: ______________________________

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