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Autobell^® Car Wash

Customer Feedback Form

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*To change the selection press left or right arrow. [Press left arrow] Yes To change the selection press left or right arrow. [Press right arrow] No Required

1. Your Contact Information

Location:NA

*Required Fields

First Name*

Please enter your First Name.

Last Name*

Please enter your Last Name.

Account Number

Email*

Please enter your Email AddressPlease enter your valid Email Address

Confirm Email*

Please confirm your Email Address.Email Mismatch

Phone Number*

Please enter your valid Phone NumberPlease enter your valid Phone Number

Full Address*

Please enter your full Address

Street Number

Route

Address*

Please enter your full Address

Apartment, Suite or Unit Number

City*

State*

Zip*

Please enter your City

Please enter your State

Please enter your Postal CodePlease enter valid Postal Code

Country

*To change the selection press left or right arrow. [Press left arrow] Yes To change the selection press left or right arrow. [Press right arrow] NoRequired

2. Car Wash Search

Please select one of the following options:* To change the selection press up or down arrow. [Press down arrow] Specific Store Location - Feedback, questions, suggestions To change the selection press press up or down arrow. [Press up arrow] No Specific Store Location - Online Order, General Inquiry, feedback, questions, suggestions

Which Wash Did You Purchase?*To change the selection press press up or down arrow. [Press up arrow]

Ride-Thru With No Wipe-Down

Outside Wash Only

Outside Wash & Inside Cleaning

No Service Purchased

When did you visit our Auto Bell?*

Date:

Visit Date

Hour

Minute

AM/PM

Visit Date

Not sure when I visited.

Search using Zip OR City,State

City

State

Zip Code

Car Wash Code

Invalid zip

Hide Map [X]

Please provide all Required information on this page.

3. Tell us about your experience, request or suggestion *

Select an item from the list below to tell us about your experience, request or suggestion. This is required. RequiredRequired Required RequiredRequiredRequiredRequired

Required

Please provide all Required information on this page.

3b. Tell us about your experience, request or suggestion *

Select an item from the list below to tell us about your experience, request or suggestion. This is required.RequiredRequiredRequired RequiredRequiredRequiredRequired

Please provide all Required information on this page.

3c. Tell us about your experience, request or suggestion *

Select an item from the list below to tell us about your experience, request or suggestion. This is required.RequiredRequiredRequired RequiredRequiredRequiredRequired

Please provide all Required information on this page.

3d. Tell us about your experience, request or suggestion *

Select an item from the list below to tell us about your experience, request or suggestion. This is required.RequiredRequiredRequired RequiredRequiredRequiredRequired

Please provide all Required information on this page.

3e. Tell us about your experience, request or suggestion *

Select an item from the list below to tell us about your experience, request or suggestion. This is required.RequiredRequiredRequired RequiredRequiredRequiredRequired

Please provide all Required information on this page.

4. Please Answer the Following:

What was the Team Member's name?.What was the Team Member's name? .

What was the Team Member's name?

Answer must be less than 2000 characters

How would you like to be contacted?.How would you like to be contacted? .

How would you like to be contacted?*

Required

Is it ok to text?.Is it ok to text? .

Is it ok to text?*

Required

First and Last Name on App Account.First and Last Name on App Account .

First and Last Name on App Account*

RequiredAnswer must be less than 2000 characters

What is the coupon code you are trying to redeem?.What is the coupon code you are trying to redeem? .

What is the coupon code you are trying to redeem?*

RequiredAnswer must be less than 2000 characters

Which Location did you visit?.Which Location did you visit? .

Which Location did you visit?*

RequiredAnswer must be less than 2000 characters

Is this a physical or e-gift card/wash pass?.Is this a physical or e-gift card/wash pass? .

Is this a physical or e-gift card/wash pass?*

RequiredAnswer must be less than 2000 characters

What is gift card number?.What is gift card number? .

What is gift card number?*

RequiredAnswer must be less than 2000 characters

Do you have the Autobell App?.Do you have the Autobell App? .

Do you have the Autobell App?*

Required

App Email:.App Email: .

App Email:*

RequiredAnswer must be less than 2000 characters

Website Email:.Website Email: .

Website Email:*

RequiredAnswer must be less than 2000 characters

Phone Number:.Phone Number: .

Phone Number:*

RequiredAnswer must be less than 2000 characters

Name on Account:.Name on Account: .

Name on Account:*

RequiredAnswer must be less than 2000 characters

Type of Fob / Key found in Customer's vehicle.Type of Fob / Key found in Customer's vehicle .

Type of Fob / Key found in Customer's vehicle*

RequiredAnswer must be less than 2000 characters

Vehicle Make, Model and Color.Vehicle Make, Model and Color .

Vehicle Make, Model and Color*

RequiredAnswer must be less than 2000 characters

Amount:.Amount: .

Amount:*

RequiredAnswer must be less than 2000 characters

Are you the Vehicle Owner?.Are you the Vehicle Owner? .

Are you the Vehicle Owner?*

Required

Relationship with Vehicle Owner? (Attorney/Family-Friend/Insurance Company or Other?).Relationship with Vehicle Owner? (Attorney/Family-Friend/Insurance Company or Other?) .

Relationship with Vehicle Owner? (Attorney/Family-Friend/Insurance Company or Other?)*

RequiredAnswer must be less than 2000 characters

Type of Wash:.Type of Wash: .

Type of Wash:*

RequiredAnswer must be less than 2000 characters

Store Location:.Store Location: .

Store Location:*

RequiredAnswer must be less than 2000 characters

First Name on App Account:.First Name on App Account: .

First Name on App Account:*

RequiredAnswer must be less than 2000 characters

First and Last Name:.First and Last Name: .

First and Last Name:*

RequiredAnswer must be less than 2000 characters

Name of Company:.Name of Company: .

Name of Company:*

RequiredAnswer must be less than 2000 characters

Code:.Code: .

Code:*

RequiredAnswer must be less than 2000 characters

Was a Incident Report / Claim completed at Location?.Was a Incident Report / Claim completed at Location? .

Was a Incident Report / Claim completed at Location?*

Required

Incident Report Number:.Incident Report Number: .

Incident Report Number:*

RequiredAnswer must be less than 2000 characters

Date of Incident:.Date of Incident: .

Date of Incident:*

RequiredAnswer must be less than 2000 characters

Date of Incident:.Date of Incident: .

Date of Incident:*

RequiredAnswer must be less than 2000 characters

Email Login.Email Login .

Email Login*

RequiredAnswer must be less than 2000 characters

What is the Error Message?.What is the Error Message? .

What is the Error Message?*

RequiredAnswer must be less than 2000 characters

Date of visit?.Date of visit? .

Date of visit?*

RequiredAnswer must be less than 2000 characters

What is the gift card or wash pass code/number?.What is the gift card or wash pass code/number? .

What is the gift card or wash pass code/number?*

RequiredAnswer must be less than 2000 characters

Stranded?.Stranded? .

Stranded?*

Required

Please give your current location..Please give your current location. .

Please give your current location.*

RequiredAnswer must be less than 2000 characters

Form of Payment?.Form of Payment? .

Form of Payment?*

Required

Last 4 #'s of Credit/Debit.Last 4 #'s of Credit/Debit .

Last 4 #'s of Credit/Debit*

RequiredAnswer must be less than 2000 characters

Name on Card?.Name on Card? .

Name on Card?*

RequiredAnswer must be less than 2000 characters

Date of Charge?.Date of Charge? .

Date of Charge?*

RequiredAnswer must be less than 2000 characters

Item:.Item: .

Item:*

RequiredAnswer must be less than 2000 characters

Name:.Name: .

Name:*

RequiredAnswer must be less than 2000 characters

Last Name on App Account:.Last Name on App Account: .

Last Name on App Account:*

RequiredAnswer must be less than 2000 characters

First and Last Name on Annual Pass or SuperCard:.First and Last Name on Annual Pass or SuperCard: .

First and Last Name on Annual Pass or SuperCard:*

RequiredAnswer must be less than 2000 characters

Organization / Company Name:.Organization / Company Name: .

Organization / Company Name:*

RequiredAnswer must be less than 2000 characters

Contact Name:.Contact Name: .

Contact Name:*

RequiredAnswer must be less than 2000 characters

Original Balance:.Original Balance: .

Original Balance:*

RequiredAnswer must be less than 2000 characters

What is your Order Number?.What is your Order Number? .

What is your Order Number?*

RequiredAnswer must be less than 2000 characters

Last 4 Digits of Credit / Debit Card.Last 4 Digits of Credit / Debit Card .

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

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

RequiredAnswer must be less than 2000 characters

Type of App Receipt.Type of App Receipt .

Type of App Receipt*

Required

Amount of Monthly Charge.Amount of Monthly Charge .

Amount of Monthly Charge*

RequiredAnswer must be less than 2000 characters

What Location gave you the coupon?.What Location gave you the coupon? .

What Location gave you the coupon?*

RequiredAnswer must be less than 2000 characters

which wash plan was selected?.which wash plan was selected? .

which wash plan was selected?*

RequiredAnswer must be less than 2000 characters

What was the original value of the gift card?.What was the original value of the gift card? .

What was the original value of the gift card?*

RequiredAnswer must be less than 2000 characters

Do you have the Receipt?.Do you have the Receipt? .

Do you have the Receipt?*

Required

Receipt Number:.Receipt Number: .

Receipt Number:*

RequiredAnswer must be less than 2000 characters

Email login for App Account:.Email login for App Account: .

Email login for App Account:*

RequiredAnswer must be less than 2000 characters

Street Address:.Street Address: .

Street Address:*

RequiredAnswer must be less than 2000 characters

Telephone Number:.Telephone Number: .

Telephone Number:*

RequiredAnswer must be less than 2000 characters

Title:.Title: .

Title:*

RequiredAnswer must be less than 2000 characters

Type:.Type: .

Type:*

RequiredAnswer must be less than 2000 characters

Please Select the Unlimited Plan Type:.Please Select the Unlimited Plan Type: .

Please Select the Unlimited Plan Type:*

Required

First and Last Name on Credit / Debit Card .First and Last Name on Credit / Debit Card .

First and Last Name on Credit / Debit Card

Answer must be less than 2000 characters

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

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

Answer must be less than 2000 characters

Reason for customer contact?.Reason for customer contact? .

Reason for customer contact?*

RequiredAnswer must be less than 2000 characters

If value is $20, is the amount printed on the front of the gift card? Yes or No?.If value is $20, is the amount printed on the front of the gift card? Yes or No? .

If value is $20, is the amount printed on the front of the gift card? Yes or No?*

Required

If yes, this is a fundraising gift card. Please give the name of the Fundraising Organization.If yes, this is a fundraising gift card. Please give the name of the Fundraising Organization .

If yes, this is a fundraising gift card. Please give the name of the Fundraising Organization*

RequiredAnswer must be less than 2000 characters

Telephone number for App Account:.Telephone number for App Account: .

Telephone number for App Account:*

RequiredAnswer must be less than 2000 characters

City:.City: .

City:*

RequiredAnswer must be less than 2000 characters

Email address:.Email address: .

Email address:*

RequiredAnswer must be less than 2000 characters

Please give the Amount Charged:.Please give the Amount Charged: .

Please give the Amount Charged:*

RequiredAnswer must be less than 2000 characters

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

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

RequiredAnswer must be less than 2000 characters

Plan Type:.Plan Type: .

Plan Type:*

Required

New Vehicle: Make, Model, and Color.New Vehicle: Make, Model, and Color .

New Vehicle: Make, Model, and Color*

RequiredAnswer must be less than 2000 characters

Who purchased the gift card/wash pass for you?(Need First & Last Name).Who purchased the gift card/wash pass for you?(Need First & Last Name) .

Who purchased the gift card/wash pass for you?(Need First & Last Name)*

RequiredAnswer must be less than 2000 characters

Have you applied via our website?.Have you applied via our website? .

Have you applied via our website?*

Required

Store / Office Location.Store / Office Location .

Store / Office Location*

RequiredAnswer must be less than 2000 characters

Need Assistance with online application process.Need Assistance with online application process .

Need Assistance with online application process*

RequiredAnswer must be less than 2000 characters

State:.State: .

State:*

RequiredAnswer must be less than 2000 characters

Zip Code:.Zip Code: .

Zip Code:*

RequiredAnswer must be less than 2000 characters

Did you submit a request via Autobell.com/donations-requests?.Did you submit a request via Autobell.com/donations-requests? .

Did you submit a request via Autobell.com/donations-requests?*

Required

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

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

RequiredAnswer must be less than 2000 characters

Please give the last 4 digits of the Credit Card used to make the purchase.Please give the last 4 digits of the Credit Card used to make the purchase .

Please give the last 4 digits of the Credit Card used to make the purchase*

RequiredAnswer must be less than 2000 characters

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

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

Answer must be less than 2000 characters

New Vehicle: License Plate Number and State.New Vehicle: License Plate Number and State .

New Vehicle: License Plate Number and State

Answer must be less than 2000 characters

Phone # given at time if purchase:.Phone # given at time if purchase: .

Phone # given at time if purchase:*

RequiredAnswer must be less than 2000 characters

Caller's Name:.Caller's Name: .

Caller's Name:*

RequiredAnswer must be less than 2000 characters

Caller's Name:.Caller's Name: .

Caller's Name:*

RequiredAnswer must be less than 2000 characters

Reason for Contacting:.Reason for Contacting: .

Reason for Contacting:*

RequiredAnswer must be less than 2000 characters

Please give the Last Billing Date:.Please give the Last Billing Date: .

Please give the Last Billing Date:*

RequiredAnswer must be less than 2000 characters

Customer Email Used:.Customer Email Used: .

Customer Email Used:*

RequiredAnswer must be less than 2000 characters

Buyers email address.Buyers email address .

Buyers email address*

RequiredAnswer must be less than 2000 characters

Caller's Title:.Caller's Title: .

Caller's Title:*

RequiredAnswer must be less than 2000 characters

Is this your App Account?.Is this your App Account? .

Is this your App Account?*

Required

What is your relationship with the owner of App Account?.What is your relationship with the owner of App Account? .

What is your relationship with the owner of App Account?*

Required

First Name:.First Name: .

First Name:*

RequiredAnswer must be less than 2000 characters

Last Name:.Last Name: .

Last Name:*

RequiredAnswer must be less than 2000 characters

Telephone Number:.Telephone Number: .

Telephone Number:*

RequiredAnswer must be less than 2000 characters

Email Address:.Email Address: .

Email Address:*

RequiredAnswer must be less than 2000 characters

Name of new Autobell Team Member:.Name of new Autobell Team Member: .

Name of new Autobell Team Member:*

RequiredAnswer must be less than 2000 characters

New Email Login.New Email Login .

New Email Login*

RequiredAnswer must be less than 2000 characters

Number of Reset Requests.Number of Reset Requests .

Number of Reset Requests

Answer must be less than 2000 characters

Old Mobile Device.Old Mobile Device .

Old Mobile Device*

RequiredAnswer must be less than 2000 characters

Mobile Device Type.Mobile Device Type .

Mobile Device Type*

RequiredAnswer must be less than 2000 characters

Autobell Order # (if available).Autobell Order # (if available) .

Autobell Order # (if available)*

RequiredAnswer must be less than 2000 characters

Name of Government Agency:.Name of Government Agency: .

Name of Government Agency:*

RequiredAnswer must be less than 2000 characters

Name of Company where Caller Works:.Name of Company where Caller Works: .

Name of Company where Caller Works:*

RequiredAnswer must be less than 2000 characters

Type of Mobile Device:.Type of Mobile Device: .

Type of Mobile Device:*

RequiredAnswer must be less than 2000 characters

Number of Vehicles:.Number of Vehicles: .

Number of Vehicles:*

RequiredAnswer must be less than 2000 characters

Date of Charge:.Date of Charge: .

Date of Charge:*

RequiredAnswer must be less than 2000 characters

Approximate Date of Referral or Hire Date.Approximate Date of Referral or Hire Date .

Approximate Date of Referral or Hire Date*

RequiredAnswer must be less than 2000 characters

New Mobile Device type.New Mobile Device type .

New Mobile Device type*

RequiredAnswer must be less than 2000 characters

Insert Error Message Received.Insert Error Message Received .

Insert Error Message Received*

RequiredAnswer must be less than 2000 characters

Old Vehicle: Make, Model, and Color.Old Vehicle: Make, Model, and Color .

Old Vehicle: Make, Model, and Color*

RequiredAnswer must be less than 2000 characters

Model Phone:.Model Phone: .

Model Phone:*

RequiredAnswer must be less than 2000 characters

Last 4 #’s of the CC used to make the purchase.Last 4 #’s of the CC used to make the purchase .

Last 4 #’s of the CC used to make the purchase*

RequiredAnswer must be less than 2000 characters

Date / Time of Video Footage:.Date / Time of Video Footage: .

Date / Time of Video Footage:*

RequiredAnswer must be less than 2000 characters

Amount(s):.Amount(s): .

Amount(s):*

RequiredAnswer must be less than 2000 characters

Amount Declined:.Amount Declined: .

Amount Declined:*

RequiredAnswer must be less than 2000 characters

Pause Request Date:.Pause Request Date: .

Pause Request Date:*

RequiredAnswer must be less than 2000 characters

Date Deceased:.Date Deceased: .

Date Deceased:*

RequiredAnswer must be less than 2000 characters

Vehicle Year:.Vehicle Year: .

Vehicle Year:*

RequiredAnswer must be less than 2000 characters

State(s) where vehicles are located:.State(s) where vehicles are located: .

State(s) where vehicles are located:*

RequiredAnswer must be less than 2000 characters

Old Vehicle: License Plate Number and State.Old Vehicle: License Plate Number and State .

Old Vehicle: License Plate Number and State*

RequiredAnswer must be less than 2000 characters

Device: Android or Apple.Device: Android or Apple .

Device: Android or Apple*

RequiredAnswer must be less than 2000 characters

Customer made aware we will investigate this information and follow up within 1-2 business days? Yes or No?.Customer made aware we will investigate this information and follow up within 1-2 business days? Yes or No? .

Customer made aware we will investigate this information and follow up within 1-2 business days? Yes or No?*

Required

Location where Employee works:.Location where Employee works: .

Location where Employee works:*

RequiredAnswer must be less than 2000 characters

Reason for Requesting Video Footage:.Reason for Requesting Video Footage: .

Reason for Requesting Video Footage:*

RequiredAnswer must be less than 2000 characters

Type of Plan:.Type of Plan: .

Type of Plan:*

RequiredAnswer must be less than 2000 characters

Old License Plate:.Old License Plate: .

Old License Plate:

Answer must be less than 2000 characters

Date of Declined Charge:.Date of Declined Charge: .

Date of Declined Charge:*

RequiredAnswer must be less than 2000 characters

Date of Charge(s):.Date of Charge(s): .

Date of Charge(s):*

RequiredAnswer must be less than 2000 characters

Number of Months (1-6 allowed:.Number of Months (1-6 allowed: .

Number of Months (1-6 allowed:*

RequiredAnswer must be less than 2000 characters

Date and Time issue started:.Date and Time issue started: .

Date and Time issue started:*

RequiredAnswer must be less than 2000 characters

What is your mailing address?.What is your mailing address? .

What is your mailing address?*

RequiredAnswer must be less than 2000 characters

Employee's Home Address:.Employee's Home Address: .

Employee's Home Address:

Answer must be less than 2000 characters

New License Plate:.New License Plate: .

New License Plate:*

RequiredAnswer must be less than 2000 characters

Reason:.Reason: .

Reason:*

RequiredAnswer must be less than 2000 characters

Last 4 Digits of Credit / Debit Card if Different From Default Card .Last 4 Digits of Credit / Debit Card if Different From Default Card .

Last 4 Digits of Credit / Debit Card if Different From Default Card *

RequiredAnswer must be less than 2000 characters

License Plate Number:.License Plate Number: .

License Plate Number:*

RequiredAnswer must be less than 2000 characters

Reason for Cancellation.Reason for Cancellation .

Reason for Cancellation*

Required

Is this related to a missing person?.Is this related to a missing person? .

Is this related to a missing person?*

Required

Who reported them missing?.Who reported them missing? .

Who reported them missing?*

RequiredAnswer must be less than 2000 characters

Detailed Description of Customer's Issue:.Detailed Description of Customer's Issue: .

Detailed Description of Customer's Issue:*

RequiredAnswer must be less than 2000 characters

State on License Plate:.State on License Plate: .

State on License Plate:*

RequiredAnswer must be less than 2000 characters

What was Guest doing in App Before Issue Started?.What was Guest doing in App Before Issue Started? .

What was Guest doing in App Before Issue Started?*

RequiredAnswer must be less than 2000 characters

Reason for inquiry:.Reason for inquiry: .

Reason for inquiry:*

RequiredAnswer must be less than 2000 characters

Reason: [insert reason for request].Reason: [insert reason for request] .

Reason: [insert reason for request]*

RequiredAnswer must be less than 2000 characters

Completed Troubleshooting Steps Taken:.Completed Troubleshooting Steps Taken: .

Completed Troubleshooting Steps Taken:*

RequiredAnswer must be less than 2000 characters

Date / Time Order Was Placed:.Date / Time Order Was Placed: .

Date / Time Order Was Placed:*

RequiredAnswer must be less than 2000 characters

Coupon / Promo Code:.Coupon / Promo Code: .

Coupon / Promo Code:*

RequiredAnswer must be less than 2000 characters

Did you share your login with a friend / family member?.Did you share your login with a friend / family member? .

Did you share your login with a friend / family member?*

Required

Order Number:.Order Number: .

Order Number:*

RequiredAnswer must be less than 2000 characters

Where did You Receive Coupon / Promo Code:.Where did You Receive Coupon / Promo Code: .

Where did You Receive Coupon / Promo Code:*

RequiredAnswer must be less than 2000 characters

Date / Time Issue Occurred:.Date / Time Issue Occurred: .

Date / Time Issue Occurred:*

RequiredAnswer must be less than 2000 characters

Item(s) Purchased:.Item(s) Purchased: .

Item(s) Purchased:*

RequiredAnswer must be less than 2000 characters

Reason for Request:.Reason for Request: .

Reason for Request:*

RequiredAnswer must be less than 2000 characters

Description of Issue / Message:.Description of Issue / Message: .

Description of Issue / Message:*

RequiredAnswer must be less than 2000 characters

On what date did you place the order?.On what date did you place the order? .

On what date did you place the order?*

Pick a Date!

RequiredAnswer must be less than 2000 characters

Email Address for E-Product if Different from Website email login:.Email Address for E-Product if Different from Website email login: .

Email Address for E-Product if Different from Website email login:*

RequiredAnswer must be less than 2000 characters

Correct Shipping Address: First and Last Name, Street Address, City, State, Zip Code.Correct Shipping Address: First and Last Name, Street Address, City, State, Zip Code .

Correct Shipping Address: First and Last Name, Street Address, City, State, Zip Code*

RequiredAnswer must be less than 2000 characters

Please provide all Required information on this page.

5. Please provide additional details about your experience *

Describe your Experience. This is a required field.

Describe your Experience. This is a required field.

Required
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