Departure Details
(
*
fields are necessary to fill departure details)
(Note: 20% Tip Compulsory)
Name
*
Pick-Up Date
*
Time
Hours
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
*
Pick-Up-Address
*
City
*
Zip Code
E-mail
*
Contact No.
*
No. of Luggage
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Passengers
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Vehicle Type
Select Vehicle
Town Car 1-4 Passengers
Van 5-14 Passengers
Limo 1-6 Passengers
Limo 1-25 Passengers
*
Instructions
Arrival Details
(
*
fields are necessary to fill arrival details)
Name
*
Airline Name
Flight No.
Arrival Date
*
Time
Hours
1
2
3
4
5
6
7
8
9
10
11
12
Minutes
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
*
Drop off Adress
*
City
*
Zip Code
E-mail
*
Contact No.
*
No. of Luggage
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Passengers
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Vehicle Type
Select Vehicle
Town Car 1-4 Passengers
Van 5-14 Passengers
Limo 1-6 Passengers
Limo 1-25 Passengers
*
Instructions
Payment Method (Credit Card):
we do not accept american express card
Card Type
--Select--
VISA
Marcard Card
*
Card No.
*
Expiration date
*
CSV No.
*
Billing Address
*
Zip Code
*
I Authorize Galaxy Town Car Services to Charge my credit card for future payment of transportation and services provided.
Signature: (please draw your signatures)
Clear Signature
