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*Required Fields

First Name*

Last Name*

Account Number

Email

Confirm Email

Phone Number*

Full Address

Apartment, Suite or Unit Number

City

State

Zip

* Yes No

Please select one of the following options:* Specific Store Location - Feedback, questions, suggestions No Specific Store Location - Online Order, General Inquiry, feedback, questions, suggestions

Which Wash Did You Purchase?*

Ride-Thru With No Wipe-Down

Outside Wash Only

Outside Wash & Inside Cleaning

No Service Purchased

When did you visit our Auto Bell?*

Date:

Hour

Minute

AM/PM

Not sure when I visited.

Search using Zip OR City,State

City

State

Zip Code

Car Wash Code

RequiredRequired Required RequiredRequiredRequiredRequired

Required

RequiredRequiredRequired RequiredRequiredRequiredRequired

Was a claim report completed with the location?*

If Yes, what is the claim number?*

RequiredAnswer must be less than 2000 characters

What was the Team Member's name?

How would you like to be contacted?*

On what date did you place the order?*

Do you need a new card issued? (if so, the following questions must be answered)*

Please enter the FIRST and LAST NAME on Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the STREET ADDRESS tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the CITY on the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the STATE on the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the ZIP CODE tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the TELEPHONE NUMBER tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the EMAIL ADDRESS tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the YEAR of your VEHICLE tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the MAKE of your VEHICLE tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the MODEL of your VEHICLE tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the LICENSE TAG NUMBER tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

Please enter the STATE on your LICENSE TAG on your VEHICLE tied to the Annual Pass or Super Card*

RequiredAnswer must be less than 2000 characters

What was the amount charged?*

RequiredAnswer must be less than 2000 characters

Is it ok to text?*

First and Last Name on App Account*

RequiredAnswer must be less than 2000 characters

Number of Reset Requests

Name of Business?*

RequiredAnswer must be less than 2000 characters

Customer Email:*

RequiredAnswer must be less than 2000 characters

What is your Order Number?*

RequiredAnswer must be less than 2000 characters

What were the last 4 digits of the card used for this charge?*

RequiredAnswer must be less than 2000 characters

Email Login*

RequiredAnswer must be less than 2000 characters

Old Email Login*

RequiredAnswer must be less than 2000 characters

What state(s) is your business located in?*

RequiredAnswer must be less than 2000 characters

Model Phone:*

RequiredAnswer must be less than 2000 characters

Please give the name on the Debit/Credit Card used*

RequiredAnswer must be less than 2000 characters

New Email Login*

RequiredAnswer must be less than 2000 characters

Old Mobile Device Type and last opened date*

RequiredAnswer must be less than 2000 characters

Last 4 Digits of Credit / Debit Card*

RequiredAnswer must be less than 2000 characters

Old Credit / Debit Card: Last 4 Digits of Credit / Debit Card*

RequiredAnswer must be less than 2000 characters

Amount of Declined Charge*

RequiredAnswer must be less than 2000 characters

Amount/Amounts Charged*

RequiredAnswer must be less than 2000 characters

Plan Type:*

Reason: [insert reason for request]*

RequiredAnswer must be less than 2000 characters

Mobile Device Type*

RequiredAnswer must be less than 2000 characters

Amount of Monthly Charge*

RequiredAnswer must be less than 2000 characters

Device: Android or Apple*

RequiredAnswer must be less than 2000 characters

What is the Make, Model AND Color of the Vehicle?*

RequiredAnswer must be less than 2000 characters

Please Select the Unlimited Plan Type:*

Please give the Date of the Charge*

RequiredAnswer must be less than 2000 characters

New Mobile Device type*

RequiredAnswer must be less than 2000 characters

Insert Error Message Received*

RequiredAnswer must be less than 2000 characters

First and Last Name on Credit / Debit Card

Old Credit / Debit Card: First and Last Name on Credit / Debit Card

Date of the Declined Charge*

RequiredAnswer must be less than 2000 characters

Date/Dates of the Charge/Charges*

RequiredAnswer must be less than 2000 characters

Old Vehicle: Make, Model, and Color*

RequiredAnswer must be less than 2000 characters

Type of App Receipt*

Date and Time issue started:*

RequiredAnswer must be less than 2000 characters

Please give the Amount Charged:*

RequiredAnswer must be less than 2000 characters

Please give the Date the charge posted to your account*

RequiredAnswer must be less than 2000 characters

New Credit / Debit Card: Last 4 Digits of Credit / Debit Card*

RequiredAnswer must be less than 2000 characters

Date/Dates the Charge/Charges Posted to the Account

Old Vehicle: License Plate Number and State*

RequiredAnswer must be less than 2000 characters

New Vehicle: Make, Model, and Color*

RequiredAnswer must be less than 2000 characters

What was Guest doing in App Before Issue Started?*

RequiredAnswer must be less than 2000 characters

Please give the last 4 digits of the Credit Card*

RequiredAnswer must be less than 2000 characters

New Credit / Debit Card: First and Last Name on Credit / Debit Card

New Vehicle: License Plate Number and State

Detailed Description of Customer's Issue:*

RequiredAnswer must be less than 2000 characters

Please give the Last Billing Date:*

RequiredAnswer must be less than 2000 characters

Please provide your Billing Address*

RequiredAnswer must be less than 2000 characters

Completed Troubleshooting Steps Taken:*

RequiredAnswer must be less than 2000 characters

Name of new Autobell Team Member:*

RequiredAnswer must be less than 2000 characters

Relationship to Deceased*

RequiredAnswer must be less than 2000 characters

Approximate Date of Referral or Hire Date*

RequiredAnswer must be less than 2000 characters

Required
2000 characters available

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