Pickup Information:                       Renters Information:

Pick Up Date: _________________________ First Name:

Pick Up Day: __________________________ Last Name:

Pick Up Time: _________________________ Home Address:

Number Of Hours: ____________________     Apt:

Location of Pickup: __________________    State: ________ Zip: ______________

State: _____________ Zip: ________________ Phone: (      )

                                           Fax: (     )________________________

                                           Email: __________________________

Contac Phone for Service Date: _________________________________

Name of Person / Group to Pick Up: _____________________________

Airline: ________________ Flight #___________ From: ______________

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Going To: ____________________________________________________





Type of Vehicle: ___________________________________

How Many Passengers: ______________________________

What is the Occasion: _______________________________

Type of Payment: _________________________________________________________

Credit Card Number for Payment / Deposit: ___________________________________

Exp: ___________________ Check Digits (Back of Card): ________________________

Type of Card: ____________Name On Credit Card: _____________________________

Age: __________________ Amount to be Paid_________________________________

Complete Billing Address: __________________________________________________

City: ________________________ State___________ Zip________________________

Signature _____________________ Date _____________________________________

This is a binding and nonrefundable rental contract between the above mention person as renter and A
Luxury Limo, Inc. I the renter, checked that all of the above information is true and correct. I authorize the
immediate deposit & the final payment. I am the authorized card holder for the above credit card. I did
receive and agree with the terms & conditions. I am responsible and liable for the full payment of the total
amount, either per cash, credit card or money order. A Luxury Limo, Inc will not accept personal or
business checks unless prior arrangements have been made. I the renter will be responsible for any damages
to the vehicle including spills to the upholstery. The charge for spills damage or excessive cleaning will be
$200.00 per occurrence. Please be cautious. Smoking is prohibited in our vehicles. A Luxury Limo, Inc.
reserves the right to up-grade vehicles according to the schedule. At no time A Luxury Limo, Inc. will
down-grade a vehicle without prior consent.

Signature: Yes I Agree._______________________ Name: _________________Date: ________________

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