E Mail Address:             

Confirmation Number:      Date of Service: 

Name (as it appears on credit card): 

Billing Address (where credit card bill is sent):     

City:   State:   ZIP:  

Telephone numbers:

Home:   Work: ext:

Fax:        Cell:

CREDIT CARD INFORMATION

Check one: Visa    MasterCard    Diners    Discover    AMEX

Card Number:    Exp. Date:

PLEASE CHARGE CREDIT CARD AS FOLLOWS:

  I authorize newyorklimousineservice.co to charge the credit card specified above the full amount of the service.  In accordance with the terms and conditions between NEWYORKLIMOUSINESERVICE.CO and the undersigned, I fully understand newyorklimousineservice.co's Cancellation Policy.  I authorize newyorklimousineservice.co to process all charges accordingly.

  I would like to establish a retail credit card account and authorize newyorklimousineservice.co to process any charges for all future service. I, the undersigned, authorize newyorklimousineservice.co to charge the above referenced credit card for transportation and related services which may be rendered through newyorklimousineservice.co and/or its affiliates.   In accordance with the terms and conditions between newyorklimousineservice.co and the undersigned, I fully understand newyorklimousineservice.co Cancellation Policy.  I authorize newyorklimousineservice.co to process all charges accordingly.

Please print Form then sign actual signature, date and fax.

Signature: ----------------------------------------------------------------        Date: ----------------------