Name: ________________________________________________________

Purpose of Account: _____________________________________________

Type of Service:__________________________________________________

Contact Person:_________________________________________________

Billing Address: ________________________________________________

City/Sate:____________________________________        Zip:___________

Phone: _________________________         Fax: ______________________   

                   Credit Card Information: (to secure account)
                       Type (Circle): MC   Visa   Amex   Discover

Credit Card Number:_______________________________________________

Exp. Date: _________________           Security Code: _______     Billing Zipcode:________

Name on Card: ___________________________________________________


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 call no less than two (2)
    hours prior to scheduled pickup time to not be 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 delays the vehicle more than 15
    minutes from the time of the scheduled pick up. Client will be charged $10 per every 15
    minutes after the grace period.   

4. Billing:
    The client has the option of choosing payment by check or credit card. Invoices will be
    sent monthly to the billing address for all the monthly service charges.

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 60 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.

8. Rates: $34 service charge, + $3/mile, + waiting time.

*This agreement shall be binding upon the party’s successors and assigned personal
representatives. This agreement shall be enforceable under the laws of the State of California
for contracts.

Client Signature__________________________________   Date___________

Print Name_______________________________  Title ___________________

Phone Number________________________________

WORLD TRANS

Medical Office  Account Contract Agreement