Direct Billing Account Application

ALL FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED.

Account Number:

Tell us about your Organization

Is your organization a ...

Hotel

YesNo

Travel Agency

YesNo

Chauffeured Transportation Company

YesNo

Parent Company Name
(if your firm is a part of larger organization)

Tell us about your Company and yourself

Company Name:*

Company Type:

EIN Number: (If Available)

D&B Number: (If Available)

Street Address:*

City / Town:*

State / Provence:*

Zip / Postal Code:*

Country:*

Booking Contact Name:*

Booking Contact Title:*

Booking Contact Business Phone Number:*

Booking Contact Mobile Phone Number:

Booking Contact Fax Number:

Booking Contact Email Address:*

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Accounts Payable Contact Information

Contact Name:*

Contact Title:*

Accounts Payable Phone Number:*

Accounts Payable Mobile Phone Number:

Accounts Payable Fax Number

Email Address:*

Bank Reference

Bank Name:*

Bank Address:*
(Street/City/State/Zip/Country)

Contact Name:*

Contact Phone Number:*

Contact Fax Number:

Email Address:*

Account Number:*

Trade Reference One

Note: Landlords, utilities, and other ground transportation companies are not accepted.

Company Name:*

Company Address:* (Street/City/State/Zip/Country)

Contact Name:*

Contact Phone Number:*

Contact Email Address:*

Trade Reference Two

Note: Landlords, utilities, and other ground transportation companies are not accepted.

Company Name:*

Company Address:* (Street/City/State/Zip/Country)

Contact Name:*

Contact Phone Number:*

Contact Email Address:*

Trade Reference Three

Note: Landlords, utilities, and other ground transportation companies are not accepted.

Company Name:*

Company Address:* (Street/City/State/Zip/Country)

Contact Name:*

Contact Phone Number:*

Contact Email Address:*

Applicant authorizes all credit references, banks and credit reporting agencies to disclose to BostonAsapCoach all pertinent information concerning the financial and credit history of the applicant.

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Credit Card on File (required)

Credit Card Account Number:*

Credit Card Expiration Date:*

Credit Card CVV Code:*

Credit Card Holder Name:*

Credit Card Billing Address:*(Street/City/State/Zip/Country)

Signature on File Authorization

I hereby authorize my signature to be on file with BostonAsapCoach for the purpose of monthly charging transportation services on my credit card for my and/or Guest use and/or Company Business Travel. I authorized the associated credit card company designated above to accept this form as in lieu of my Personal signature appearing on credit card receipt for transportation services rendered.

E-Signature of Approver

Please note that approver must be authorized user of the above listed Credit Card. By typing your name, you are authorizing BostonAsapCoach to charge above listed Credit Card for Monthly Payments.

E-signature:*

Date:*

Payment Options

BostonAsapCoach offers the following Payment options:

Payments can be made by ACH deposit electronically or by US mail eash month.
Payments can be applied to a single Credit Card at the end of each month

Terms of Payment

Invoices are due upon receipt. A late fee of 2% per month will be added to all invoices that have not paid within thirty (30) days after the invoice is received. In case of errors or questions with regards to your invoice, BostonAsapCoach must hear from you within 3 weeks of receiving the invoice in writing, on which a specific issue has appeared. You may withhold the payment on the amount in question while we are investigating the charge(s). You remain obliged to pay any part of the invoice that is not in question including any late fee.
In the event of your account is outstanding in excess of sixty (60) days, it will be considered as a delinquent or in default. BostonAsapCoach reserves the right to place accounts that are determined to be delinquent or in default on credit hold and charge the Credit Card on File for the balance owed, including any late fee. Additionally, if a Credit Card on File is inactive, expired, or for other reason is not charged the outstanding balance owed, BostonAsapCoach reserves the right to initiate a collection proceeding on such accounts. BostonAsapCoach will collect any and all attorney's fees, collection expenses, and court costs incurred by BostonAsapCoach in its effort to collect the outstanding balance owed. Additionally, BostonAsapCoach reserves the right to convert all overdue accounts to a credit card only status for the service provided in the future.
By signing this Direct Bill Account Application, you agree to the terms of this application, and consent to BostonAsapCoach contacting the credit references listed herein.

E-Signature of Approver

Please note that approver must be an officer or authorized agent legally able to bind the Company.

E-signature:*

By typing your name in the box above and submitting this application electronically, you are authorizing BostonAsapCoach to verify the above information, contact your bank and other trade references, research your credit history including Dunne & Bradstreet inquiry and provide information about our credit experience with you. You are also agreeing to our Payment Terms & Conditions.

Title of Approver

Title:*

Date:*

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