Fax this form to: 1 (201) 623-2501. Please note incomplete charge account applications can not be processed. Thank you!

Company Information

Account Payable Information:

Bank Information:

(if you bank with Citibank, you must provide the name and direct telephone number of your bank officer)

Trade Reference:

Applicant authorizes all credit references, banks and credit reporting agencies to disclose to Empire Limousine All pertinent information concerning the financial and credit history of the applicant. A $1.00 per voucher service charge and 20% gratuity charge will be automatically added to your bill. Empire Limousine reserves the right to refuse service to individuals who are in arrears. Customer agrees to be responsible for payment off all lost, stolen or missing vouchers. Customer agrees to be responsible for all reservations made resulting in a "no show". Interest rate for late payment will be calculated at 16% per annum. In event of non payment, all legal and collection fee will be added to your bill. With my signature below, I hereby authorize Empire Limousine to submit unsigned credit card vouchers on my behalf for services rendered, stating that my signature is on file.

If you have any questions please call 1 (877) 664-3030 Payment Terms: 10 days net

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