ModWash Customer Cancellation Form
Customer Name:
*
First Name
Last Name
Customer Email Address:
*
example@example.com
Customer Phone Number:
*
Please enter a valid phone number.
Customer License Plate #:
*
Credit Card Type:
*
Please Select
VISA
MasterCard
AMEX
DISCOVER
Other
Last 4 Digits of Credit Card:
*
Date Submitted:
*
-
Month
-
Day
Year
Date
City/Town of Residence:
*
State of Residence:
*
What ModSite did you purchase a membership from?:
*
Reason for Cancellation:
*
Please Select
Description
Customer specifically refuses to state.
Customer states never agreed to membership.
Financial
Hurricane/Natural Disasters
Inconvenient Location
ModWash Reasons
Moved
Not Using
Other (notate on account)
Price Increase
Quality of Wash/Serv
Requested by Location
Seasonal
Value/Price
Vehicle Problem
Vehicle was Damaged
What measures can ModWash implement to enhance your overall experience? Would a special pricing offer be effective in encouraging you to maintain your membership with ModWash?:
*
Customer Signature:
*
Geo Stamp:
Submit
Should be Empty: