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Please Fill In The Following Information

First Name:	*	Last Name:	*
Street Address:	*	City:	*
State/Prov:	*	Zip/Postal:	*
Country:	*
Phone:	*
Fax:		(Some transactions require completion of a Credit Card Authorization form, if we fax you one please fill it out and fax it back to us within 24 hours.)
Mobile Phone:		Your Email:	*

Pick Up Information

Street Address or Airport Name:	*
Address2 or Airline Name:	* required for airline name only
City or Arriving From:	*
State/Providence or Flight No.:	*
Zip/Postal Code or Arrival Time:	* (example: 16:30)
List Passengers:

Destination

Destination:	*
Other:
Address:		City:
State/Prov:		Zip/Postal:
Number of Passengers:		Suitcases:
	*NOTE: 6 or more suitcases will require Luxury Van or Limousine.
Type of Car:	*
Date of Pickup:	*
Time of Pickup:	*
Drop Off Time:	*

Comments

By Checking this box you have agreed that you have viewed Long Island Car and Coach Terms and Conditions

You will need a valid credit card to place a reservation (unless you have an existing account).
If the credit card won't be available for imprint by driver either at the pickup or drop-off location,
we must then get a credit card authorization form by fax or e-mail from the credit card holder.

View Terms and Conditions

By submitting this form you agree that (1) That you are requesting the services listed above for a Free Quote

I AGREE

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Long Island Car and Coach
Telephone :516-851-2600 Office: 516-596-8548
Fax: 516-596-8635

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