between (hereinafter designated as "Owner")
and Clean Cars, Inc. of 6 Laurier St. Worcester, MA 01603

Vehicle Information

1 My make/model is not listed

Owner Information



By signing the document, the owner agrees:

  • The vehicle is fully insured and registered.
  • Owner understands that their car insurance will be used to cover the automobile while in the posession of Clean Cars, Inc. As stated in owner's insurance policy.
  • To relieve Clean Cars, Inc. of any liability in the case of a collision.
  • The vehicle is in mechanically sound condition and is safe to drive.
  • All information provided on this form is accurate.

Clean Cars Inc. agrees:

  • That the automobile be handled with the utmost care and only be operated by licensed drivers who are at least 21 years of age.

Email Address (You will be emailed a copy of the information you submit for your records)

Owner Signature     Date