Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you Purchased your VIP Membership onsite?

Yes

No

Terms & Conditions *

Xtreme Clean's VIP Wash club provides specified number of car washes in each month membership is renewed. Membership can be cancelled at any time. Member must notify Xtreme Clean at least 7 days prior to renewal date. No refunds or credits will be transmitted toward partial periods or unused washes. Washes do not roll over from month to month. There are no refunds, credits or adjustments for days or times that a car wash is temporarily closed due to inclement weather or maintenance. Only the car listed on this form is eligible for the program and must have an Xtreme Pass affixed to the driver's side of the windshield. Damaged tags should be reported to Xtreme Clean immediately. Any attempt to remove the tag will destroy the tag and keep it from operating and the member will be charged $5 for tag replacement. Member must notify Xtreme Clean of any change in vehicle ownership. By enrolling in the VIP Wash Club program, member agrees that the credit card provided can be charged every month on the renewal date until cancelled. Member agrees to waive any and all right to withhold or delay payment of the related credit card charges, whether as described in member agreement with the credit card issuer or otherwise.

Yes, I have read and agree to the terms and conditions.