Online Reservation Request

Reservation Request

First Name

Last Name

Company Name (If Any)

Phone #

Cell #

Fax #

Email Address

Pick Up Date

Pick Up Time

# of passengers

Type Of Vehicle

Address 1

City

State

Zip

If The Pick Up Is Different Or
Arival Information

Pick Up Phone Number

Itinerary

Drop Off Address If Different then above
Or Airport & Airlines Information

Is this A Pick Up Or Drop Off At An Airport?

Is A Return Needed

Return Date

Time

Departing Airport

Returning Flight Information

After choosing Pay Pal as a credit card a request for funds will be sent to the email address you provided at the beginning of this form with reservation numbers. That price will be the total including 20% gratuity for the chauffer. If you would like to tip the chauffer more with Pay Pal please put the amount in the notes on this reservation request because there can be no additions after the request for funds is sent.

Payment Type

Credit Card Number

CVV #

Credit Card Billing Adress

0/255 characters

Note: A Dispatcher from Roger's Livery Service will call you to confirm this reservation. If you need service in less that 8 hours please call 888-596-0367
Thank You

Was This Reservation Made By The Passenger

Non Passenger Information

Notes

After Completing This Form You Will Be Directed To
www.rogerslivery.com

Indicates Response Required

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