AFFILIATE REGISTRATION FORM

    AFFILIATE REGISTRATION FORM

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

    Account Number:

    Transportation Company Information

    Company Name*:

    Street Address*:

    Street Address*:

    City / Town*:

    State / Province*:

    Zip Code / Postal Code*:

    Country*:

    Business Number*:

    Fax Number:

    Email*:

    Business Model:

    Contact Information

    Contact Name*:

    Contact Title*:

    Contact Phone Number*:

    Contact Mobile Phone Number:

    Contact Fax Number:

    Contact Email Address*:

    Operations Information

    Market(s) Served*:

    City / Town*:

    Hours of operations*:

    24Hrs. Dispatch Number (if available):

    What dispatching software you use?*:

    Appropriate level of insurance coverage*:

    All certificates from operating authorities*:

    Fleet Information

    Vehicle Types

    Please check all that apply*:

    Additional Information:

    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 above box and submitting this application electronically you are certifying that the above listed information is correct and you have read and agreed with the Affiliate Terms & Conditions published on Diplomat Limousine Service website. Also authorizing Diplomat Limousine Service to verify the above information anytime if needed.

    Title of Approver

    Title*:

    Date*::

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