Request Form

Sample request form

Region: 01 - IA, IL, WI, MN, MO

    Donovan Trana                                                                    Phone: 563-785-6215
    2196 Union Ave.                                                                  Cell: 563-299-0144
Wilton, IA 52778                                                                   Fax: 563-785-6215

E-Mail: dtrana@expresssolutions.us

Information Request Form

Note! All information is held strictly confidential - we will never sell your information!

To receive your free sample, complete the form below. Your Regional Distributor will contact you within 2 business days to confirm the information. Not a pressure sales call, but a thank you and conformation of information. Your sample will be shipped and you will be given a Customer ID# and password which can be used at anytime for future orders. The only requirement will be that you fill out the survey, which will be sent with the sample, evaluating the soap and return it after using the soap. We appreciate any and all correspondance related to the operation of car washes and the chemicals used. Helping you service your customers in the most efficent way is what we are about. Thank you for your time.

* Required Information

Business Name *	______________________________________
Contact Name *	______________________________________
Shipping Address
Street Name *	______________________________________
City *	______________________________________
State *	______________ Zip Code * _______________
Phone # *	________________ Fax # _________________
Cell #	______________________________________
E-mail Address	______________________________________
Savings Code	______________________________________

How many car wash locations do you own or operate?

Do you use a liquid or powder soap?             Powder           Liquid     Hybrid (combination)

Are you satisfied with the performance of your soap?    Satisfied Somewhat Satisfied NOT

Do you feel you are paying to much for Soap?  Way too much   Pricing is O.K. Great pricing

Comments, Questions or Special Instructions:

Thank you! We will be in contact with you within 2 business days of receiving this.