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

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

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

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