Client Application and General Information

Company Name    Service Class (click on one) Executive-Black Car Chairman Class

Address

City   State   Zip

Main Phone   Fax  

Your Name   Title

Your Phone   e-mail address

Please indicate how you heard about us

Billing

Billing Contact Name   Title

Billing Contact Phone   e-mail address

Additional Information that may be required by your company that we need to collect at the time of reservation (please check one):

Department   Cost Center    Other

Credit Card Information (required if your estimated weekly billing is less that $250)Name on Card

Name on Card    Company on Card

Click on Card Type CreditCard Visa AmEx Master Card Discover Diners   Card No. Expiration (mm/yy)

Additional Information

Gratuity for the driver:    Please select: 15% 20%

Do you require pre-printed vouchers? Yes No               If you require VIP cards, please click here to enter a traveler profile

Waiting time in minutes that are authorized if the passenger or administrator is not available

General Terms and Conditions

The company or individual stated is responsible for all charges, orders and rides taken on the account. A service charge is added to each job on the invoice (voucher charge) as well as the 2% New York Surcharge Tax. See your specific agreement, or our website for the latest rates.  All rates are subject to change with notice:  http://www.eastcoastlimousine.com/Terms&Conditions.htm  The company or individual who is establishing this account also agrees not to solicit or engage in any manner of employment any chauffeur, driver or employee of Exectransport, Inc. The individual submitting this online application acknowledges that they are authorized to engage in this agreement.

I have read and agree to the terms and conditions (please click on the word Yes)   Yes No

Please enter name as a representation of your signature 

Name   Title   Date