Client Account Application and General Information

Company Name    

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 for individual accounts, and corporate accounts if estimated weekly billing is less that $250)

Name on Card    Company on Card

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

Gratuity for the driver. Please select: 15% 10% 5% Will Decide In Car No

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:  See Terms and Conditions. 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