NAME

TITLE

COMPANY (if corporate account)

BILLING ADDRESS

CITY STATE ZIP

PHONE FAX

E-MAIL

NO. OF DEPTS. USING THIS ACCOUNT

PAYMENT OPTIONS

1. CREDIT CARD You will receive an itemized monthly statement with the total amount, which will be then charged to your credit card. (all major credit cards welcome!)

NAME on card

CARD TYPE

NUMBER EXP. DATE

2. MONTHLY BILLING will be mailed to you and is payable on receipt.

Please furnish three trade credit references and allow time for processing.

NAME

ADDRESS PHONE

NAME

ADDRESS PHONE

NAME

ADDRESS PHONE

ADDITIONAL INFORMATION

Please provide the following information about what type of service you require:

Type of account:

INDIVIDUAL CORPORATE

If corporate, number of individuals expected to use our service:

FEWER THAN 5  5-10 MORE THAN 10

Number of expected pick-ups/deliveries per week:

FEWER THAN 5  5-10 MORE THAN 10

MOST FREQUENT DESTINATIONS:

Check here if you would also like to be enrolled in a voucher program

I acknowledge that I am duly authorized to sign and have read and accept all terms & conditions set forth herein by the New Town Taxi Association, Inc.