GTLMT Credit Card Authorization Form

Card Type

Mastercard

VISA

Discover

Amex

Other

Cardholder Name

As shown on Card

First Name

Last Name

Email Address

Phone Number

Card Number

Expiration Date

Security Code

Cardholder Zip Code

From Credit Card Billing Address

By entering my name below, I authorize The Germantown Laundromat to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.