NATIONWIDE LIMOUSINE
CHARTER RESERVATION FORM
All items marked with an asterisk (*) are required for confirmation.

Company Name:

*Contact Name:

Account / P.O. #

*Contact Phone:

*First name:

*Last Name:

*Billing Address :        Number of Passengers:

*City:             State:       Zip: 

*Home Phone:

Work Phone:

Cell Phone:

Fax Number:

*Email:   

*Pickup Location:         *Phone:
Pickup Location #2:     Phone:

Stops:
(Itinerary)

*Drop Off Location:    *City:
*Vehicle Type:          
*Type of Payment:       

If corporate account please provide BILL TO Account Number:

Charter Service

*Date of Service:

*Pickup Time:

Drop Off Time:

Do you expect to go overtime?                   If yes, how long?  HRS

Additional Information:
(Itinerary)