CORPORATE ACCOUNT APPLICATION

Company Information

Company Name *

Adress *

State *

Zip *

Phone *

Fax *

Web Site

Billing Contact Information

Bill Attention to *

Title

Extention Number

Cellular Phone

E-mail

Fax Number (if other)

Contact Information

Contact Name

Title

Extention Number

Fax Number (if other)

E-mail

Credit Card Information

Credit Card Type *

Credit Card Number *

Credit Card Exp Date *

Tax id Number *

Business Information

Nature Of Business

Trade Reference

Reference Contact Name

Reference Contact Number

This agreement is subject to the terms and
conditions appearing on this . No modifications or additions shall be binding upon.
Elie's Limo unless agreed to in writing.
Elie's Limo makes no warranty of any kind, express or implied, as to the service covered hereby except as provided on this agreement.
This order will become a contract only when
submit by customer with this form.

Accepted By

Name

E-Mail (Will send confirmation E-mail)

Date *

Sign