WCCW Account Application Form

Central Car Wash : Account Application Form
Billing Information:
Contact Name:*

First NameMiddle NameLast Name
Phone Number:*

Area CodePhone Number
Is this for a Business?*

YesNo
Business Name :*
Mailing Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address :*
A copy of your application will be sent to this address
Account Type :*
Select Payment Terms
Due to PCI compliance we cannot collect credit card data online. We will contact you when we process the rest of this application.
Account Credit Limit Requested :*
$ CDN
WashCard Details:
How Many Cards Do You Require?*
Card #1 Printed Name :
Card #2 Printed Name :
Card #3 Printed Name :
Card #4 Printed Name :
Card #5 Printed Name :
Card #6 Printed Name :
Card #7 Printed Name :
Card #8 Printed Name :
Send Application:
TERMS OF ACCOUNT APPLICATION: By clicking the submit button below, I certify that all of the information provided on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, this application may be rejected and, if an account has already been created, it may be terminated at any time. In consideration of this application, I acknowledge that it is the account holder's sole responsibility to prevent unauthorized usage for all wash cards and to immediately report any lost or stolen cards. The account holder agrees to provide prompt payment for all account usage including that which may have been incurred by unreported lost or stolen wash cards.*

I have read & agree to the above Terms of Account Application.
Signature*

Clear
Should be Empty:

Central Car Wash : Account Application Form

Billing Information:

WashCard Details:

Send Application: