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Bens Premium Limousine Fax Reservation

Date: _______________________________________________________

Time of Pick Up: _______________________________________________________

Name of Passenger: _______________________________________________________

Pick Up Location: _______________________________________________________

For airport pick ups specify airport, airline, flight #, and city of departure

Telephone #: _______________________________________________________

Destination: _______________________________________________________

Number of Passengers: ________
Pieces of Luggage: ________

Vehicle needed:
Certain luggage restrictions apply
Sedan [ ]
(1-4 pass)
Limousine [ ]
(1-10 pass)
Van [ ]
(1-14 pass)

Form of Payment:
Card holder must be present in the car
Cash [ ]
AE [ ]
VI [ ]
MC [ ]
DC [ ]

Credit Card #: _________________________________________
Exp. Date: _________

Specific requests or directions:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Fax completed form to (718) 706-8790

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