Personal Account Application

Name of the person opening the account *

Address *

Country

City

Phone *

Mobile Phone

Fax Number

Email *

Passenger's Details

Passenger's Name *

Passenger's Address *

Apt, suite, etc.

Country

City

Zip code

Passenger's Home Phone *

Passenger's Mobile Phone

Passenger's Email

Employer

Employer's Address

Employer's Phone Number

Current Position

Annual Salary

Years with current company

Financial Information

Bank / Trust Company

Bank Address

Account Number

Major Credit Card Number *

Expiry Date *

Billing Options

Email Invoice

Fax Invoice

Fax and Email Invoice

Billing Email

Billing Fax Number

PLEASE BE ADVISED THAT A DEPOSIT EQUAL TO THE VALUE OF ONE MONTHS WORTH OF TRIPS MAY BE REQUIRED

In applying for credit with Wheelchair Taxi Online., the undersigned consents to Wheelchair Taxi Online . obtaining from, exchanging with or disclosing to a third party all information concerning the Application for the purpose of ensuring the accuracy of this information and conducting investigations. The undersigned hereby authorizes Wheelchair Taxi Online. through an affiliated company to collect Any overdue balance on my account by charging one of the above credit cards

Signature

Reset Signature

Date