Name: _______________________________________

Birthdate: ___________________________ Male/Female

Address: _____________________ Zip Code: ________

City: ________________________ State:____________

Telephone Number:______________________________

Email Address: _________________________________

License Plate #: _______________________

Car Make: ___________________Model: ____________

Year: _________________ Color of Car: ____________

(Please Print Clearly)


 PLU #3061

1/2 Price Wash on Your Birthday!
and $1.00 off when you bring us the form.
(Print this page and fill it in)


19th & Bell Street  Fremont, Nebraska

— The Midwest’s Best Car Wash –