HETRA Blanket Services Intake Form

HETRA Blanket Services Intake Form
Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Blanket #1
Color, Brand, Size*
Blanket Category*
Light or Heavy Soil?*
Would you like your blanket waterproofed?*

Yes ($7)No
Number of rips/tears (under 1 inch)
Blanket #2
Color, Brand, Size
Blanket Category
Light or Heavy Soil?
Would you like your blanket waterproofed?

Yes ($7)No
Number of rips/tears (under 1 inch)
Blanket #3
Color, Brand, Size
Blanket Category
Light or Heavy Soil?
Would you like your blanket waterproofed?

Yes ($7)No
Number of rips/tears (under 1 inch)
Please understand we don't take blankets with large tears (over one inch). We do not take responsibility for further damage which could occur to a blanket that has tears of any type.*

I understand
Signature*

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Drop off is by appointment only. Please wait for a confirmation email or phone call to determine drop off date/time as well as pick up date and time. Please call us at 402-359-8830 for questions.
Preferred Drop off date*

MonthDayYear
Date
Preferred Drop off time
Preferred Pick up date*

MonthDayYear
Date
Preferred Pick Up Time
Comments
Signature
Total Due*

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USDHETRA Blanket Washing Services
Calculation

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Contact Information