WORLD TRANS Board & Care  Account Contract Agreement Name: _____________________________________________________ Purpose of Account __________________________________________ Type of Service______________________________________________ Contact Person:_____________________________________________ Billing Address: ____________________________________________________________ City/Sate___________________________________________________Zip ____________ Phone: _________________________Fax: ______________________ E-mail: ___________________________________________________ Credit Card Information: (to secure account) Type (Circle): MC   Visa   Amex   Discover Credit Card Number: _______________________________ Exp. Date: _____________                  Name on Card: ________________________________   Security Code# ___________ Terms and Conditions of Service: In an effort to provide our clients with excellent call response,WORLD TRANS Requests our clients to observe the following terms and conditions. 1. Service Calls/ Appointments: Service calls/appointments shall be made no less than two (2) hour proceeding the intended Pickup time. WORLD TRANS shall not guarantee prompt pick-up for calls made less than two (2) hour prior to the intended pick-up time. Such calls will be honored based upon availability of vehicles and upon assessing the distance between available vehicles and pick-up point. 2. Cancellation of Service Calls: Clients must cancel service calls no less than two (2) hours prior to scheduled pickup time to avoid being charged for the service. After that period, if the driver is en-route, or has arrived at the pick-up location, the client's account will be billed $34.00 3. Waiting Period: Clients will pay an additional surcharge if the client is delayed more than 15 minutes after his/her scheduled time of pickup. 4. Billing: The client has the option of choosing payment by check or credit card. Invoices will be sent monthly to the billing address. 5. Payment: A credit card number is required to secure the account. Invoices shall be paid no later than 30 days after receipt of invoice. If account balance remains unpaid after 30 days, WORLD TRANS reserves the right to charge the credit card on file for the full amount of the balance due. The client agrees to pay all collection costs and attorney's fees related to payment of the client's account. 6. Indemnity: WORLD TRANS shall maintain a comprehensive insurance policy on all its vehicles. The liability of WORLD TRANS for damage to client(s) body or property shall not exceed the amount Recoverable from such insurance. 7. Late Pick-Up Fees: Pick-ups after 7pm and before 7am will be charged an additional $15 night call surcharge . 8. Rates: For wheelchair pick-ups the service rate is $34 + $3/mile + any additional fees that may apply such as waiting time or late pick-up rates. Mileage is charged from the point of pick-up to drop-off. Gurney pick-up rates will be provided during reservation periods. *This agreement shall be binding upon the party’s successors and assigned personal representatives. This agreement shall be Enforced under the laws of the State of California Signature______________________________________________Date_______________ Print Name_______________________________ Title_____________________________ Phone___________________________________________________________________