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 Crown limo LA DBA CorporateLimoLA.com to charge the credit card specified above the full amount of the service.  In accordance with the terms and conditions between CorporateLimoLA.com and the undersigned, I fully understand CorporateLimoLA.com's Cancellation Policy.  I authorize CorporateLimoLA.com to process all charges accordingly.

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

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

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