Customer Information

Title:	First Name:	Last Name:
	Phone:	Ext.:
	Cellphone:	E-mail:

Pick-Up Information

Reservation Type:

Date of Service:

Pick-Up Time:

No. Passengers:

No. Wheelchairs:

Wheelchair Type:

Airport:

Airline:

Flight #:

Arriving From:

Or:

Address:

City:

State:

ZIP:

Stop #1:

Stop #2:

Destination Information:

Airport:		Airline:
Flight #:
Or:
Address:		City:
State:		ZIP:

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Discount Code:
Payment Information
You will not be billed until the services are rendered!
Card Type:
Expires:
Card Number:	Security Code:
Name on Card:

Additional Information

Please use this space for additional stops, special requests or other important information regarding this reservation:

NOTE: Online reservations must be made at least 48 hours in advance. Your reservation is not complete until you receive a confirmation number. For immediate service, please call our office toll free at 888 507 0500. If you prefer to send your reservation via fax, please fax your completed form to 718 507 1688.

The credit card holder MUST be present at the pick-up location. If you are paying for someone, please print and fax your reservation with a copy of the front and back of the credit card to 718 507 1688.

By submitting this form, I understand and agree that:

I am the credit card holder.
I am requesting the services listed above.
I am authorizing Vega Transportation to charge this credit card for the requested services.

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Customer Information

Pick-Up Information

Destination Information:

Discount Code

Payment Information

Additional Information