Wash Ticket Order Form | Submitting Form | Billing Info

Print and Use this coupon at either location!

Please complete all sections of this order form:
Incomplete forms will not be processed
Please note: At this time our website is not secured for
taking credit card orders online. To insure your privacy
is maintained, please fill out this form, print it and fax or
mail it to us. fax number & mailing address

* Underline fields are required. (not underlined are optional)
* Place a hyphen (-) in fields that are not applicable.
* If you are unable to use this form you may print it out and send it with
payment to the address noted below.

Wash Ticket Order Form
A great car maintenance idea for you.
A great gift idea for a friend!
Use this handy order form to order any number of wash tickets you need. Prices updated March 2006. We reserve the right to change prices without notification.

ULTIMATE WASH TICKETS(Note quantity in appropriate box)

01-04 X $12 each	05-94 X $11 each
10-49 X $10.50 each	50-99 X $10.25 each

SUPER WASH TICKETS(Note quantity in appropriate box)

01-04 X $9 each	05-09 X $8 each
10-49 X $7.50 each	50-99 X $7.25 each

WASH & WAX TICKETS (Note quantity in appropriate box)

01-04 X $8 each	05-09 X $7 each
10-49 X $6.50 each	50-99 X $6.25 each

WASH TICKETS (Note Quantity in appropriate box)

01-04 X $7 each	05-09 X $6 each
10-49 X $5.50 each	50-99 X $5.25 each

Allow 1 to 2 weeks for delivery.

Billing Information

First Name
Last Name
Address
City
State/Province
Zip/Postal Code
Email
Day Telephone
Evening Telephone
Fax
Payment Method
Credit Card Number	- - - Expiration Month: Expiration Year:

To Submit This Order
Please note: At this time our website is not secured for
taking credit card orders online. To insure your privacy
is maintained, please fill out this form, print it and fax or
mail it to us. fax number & mailing address

Please verify that all of the information you have entered is complete and accurate. If ordering by Visa or MasterCard, select the submit button below. Once you submit your order, a confirmation page will be returned. If ordering by check or money order, print this order form and send a copy of the order and payment to:
Stay Clean, Inc.
P.O. Box 905
Grandville, MI 49468

Corporate office phone: 616.776.5950
Corporate office fax: 616.776.5951

To submit

To cancel your order, click here to return to the main page:
Stay Clean, Inc

Wash Ticket Order Form | Submitting Form | Billing Info

Print and Use this coupon at either location!

To Submit This Order Please note: At this time our website is not secured for taking credit card orders online. To insure your privacy is maintained, please fill out this form, print it and fax or mail it to us. fax number & mailing address

To Submit This Order
Please note: At this time our website is not secured for
taking credit card orders online. To insure your privacy
is maintained, please fill out this form, print it and fax or
mail it to us. fax number & mailing address