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      Name *
      Address *
      Phone Number *
      E-mail *
      Pick-Up Date
      Pick Up Time
      Delivery Date
      Delivery Time
      Preferred Laundry Detergent
      TideGainAll Free & ClearI Will Provide
      Bleach Whites
      YesNo
      Laundry Bag Needed?
      YesNo
      Line Dry Items Included (Limit 5 Items)
      Special Instructions *