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Today's Date:   Phone Number:
    email Address:
Party Type
Vehicle Type
Date of Service: Pick up Time: AM PM
Special Instructions:
As Per:
Customer Name:
Pick- Up Address: City:
State: Zip Code:
Phone #: Destination:
Cross Street @ Pick up address
StripClubPartyBus.com is hereby authorized to reserve a limousine for the stated time via the credit card listed below and/or charge my credit card for all the transportation charges that are incurred at my request. This authorization, once submitted, is valid whether or not a charge slip has been signed. If for any reason the account balance is not paid, I agree that I will be liable for any and all reasonable legal fees and costs, in addition to the outstanding balance. All information will be kept strictly confidential.
 
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Full Name On CC: Credit Card #:
Billing Address On CC: Expiration Date:
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Home Phone: Office #:
Signature: Date Signed:
 
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