Date of Prom __________________________ 

Limousine Requested __________________________ 

Name of Party _______________________________________________________________________________

Address ____________________________________________________________________________________ 

Home Phone # _________________________ 

Work Phone # ________________________________ 

Pick-Up Time __________ Pick-Up Address _______________________________________________________ 

Time of Reception ______________________ 

Name and Location of Reception ________________________________________________________________

Rate _________________________________ 

Amount of Deposit _____________________________ 

CASH Balance Due __________________________ 

Method of Deposit      Cash    Check    Credit Card 

*Credit Card Number (Mandatory) _____________________________ Expiration Date ____________________ 

Name on Credit Card (If Different From Above) _____________________________________________________ 

Special Instructions __________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

__________________________________
Signature of Credit Card Holder 

*A CREDIT CARD NUMBER IS NECESSARY TO PROTECT US FROM DAMAGE TO THE LIMOUSINE RESULTING FROM MISUSE OR NEGLECT.

 PLEASE NOTE: 

CONSUMPTION OF ALCOHOL OR USE OF DRUGS WILL NOT BE TOLERATED. THE DRIVER WILL RETURN TO THE PICK-UP ADDRESS IMMEDIATELY IF THERE IS A VIOLATION OF THIS RULE AND NO REFUNDS WILL BE GIVEN! THE DIVIDER WINDOW WILL BE DISABLED BECAUSE THE DRIVER IS RESPONSIBLE BY LAW FOR ANY ILLEGAL ACTIVITIES THAT MAY OCCUR IN THE BACK OF THE LIMOUSINE.

PLEASE NOTE:
20% GRATUITY FOR THE DRIVER IS NOT INCLUDED!