By submitting and signing this form, I confirm:

By submitting and signing this form, I authorize Star Brite Car Wash to change my wash level to the selection above and to bill my provided debit or credit card at current rates for the newly selected level, plus applicable Pennsylvania sales tax. Any additional vehicles on my account will be billed at the current add-on rate for the new level. My payment method on file also remains authorized for any à la carte extras or single-wash add-ons I purchase at the kiosk during my visits. Membership continues to renew automatically on my anniversary date. Current rates: Shimmering Star $25/mo, Shining Star $35/mo, Shooting Star $40/mo. Additional vehicles: Shimmering $12/mo, Shining $17/mo, Shooting $20/mo. Star Brite Car Wash reserves the right to cancel any membership at any time for misuse or abuse. I may cancel at any time at StarBriteCW.com/cancel or in-store.