Enrollment

Jack Splash Mattoon Enrollment Form

Complete and submit to a cashier at participating stores

Vehicle and Package Information:

Make:

Model:

License Plate #

Check One:

Please provide the required field.

Name:

Address:

Day Phone:

Email Address:

Employee Initials:

Terms, Conditions, Purchase Agreement

Please provide the required field.

I agree to the terms and conditions stated above:

Please provide the required field.

Applicant Signature:

Date:

Please provide the required field.
Phone: 217-234-5888

Note: No refunds for partial periods