Customer Information

Customer/Company Name:*

Customer/Company Address:*

City/State/Zip:*

Phone Number:*

Fax Number:*

Contact Name For Payment:*

Email Address:*

Corporate Password: (maximum 8 characters)*

Would you like a tip included: Yes, please include a tip.

If yes, please check this box and specify the tip amount below. If no, please leave this checkbox empty and skip to the billing information.

Tip Amount: Select an option... 10% 15% 20% Other No Tip

If you wish to leave an amount other than the amounts listed above, please specify here:

Billing Information

Address:

City/State/Zip:

Phone Number:

Fax Number:

Additional Information

Type of Business:* Select an option... Corporation Partnership Individual

Federal ID Number or Social Security Number:*

Years in Business:

Previous Address (if less than 2 years):

Bank Information

Bank Name:*

Address:*

City/State/Zip:*

Account Number:*

Bank Officer to Contact:*

Phone Number:*

Fax Number:*

Credit Reference #1:

Company Name:*

Address:*

City/State/Zip:*

Account Number:*

Phone Number:*

Fax Number:*

Average Payment History:* Select an option... 30 Days 60 Days 90 Days Other

Credit Reference #2:

Company Name:*

Address:*

City/State/Zip:*

Account Number:*

Phone Number:*

Fax Number:*

Average Payment History:* Select an option... 30 Days 60 Days 90 Days Other

Credit Reference #3:

Company Name:

Address:

City/State/Zip:

Account Number:

Phone Number:

Fax Number:

Average Payment History: Select an option... 30 Days 60 Days 90 Days Other

Terms

Agreement:*
By checking this box, I agree that I have read,
understand, and agree to comply with the terms and conditions
set forth by Metro Taxi. I also understand that checking this box acts
as my digital signature on this application.

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