Manage My Membership

ModWash Customer Cancellation Form

"*" indicates required fields

Customer Name*

First Last

Customer Email Address*

Customer Phone Number*

Customer License Plate #*

Credit Card Type*

Other (Credit Card Type)*

Last 4 Digits of Credit Card*

Date Submitted*

City/Town of Residence*

State of Residence*

What ModSite did you purchase a membership from?*

Reason for Cancellation*

What measures can ModWash implement to enhance your overall experience? Would a special pricing offer be effective in encouraging you to maintain your membership with ModWash?*

Customer Signature*