Northeastern Limousine
EXECUTIVE CAR SERVICE
2 Elm Street, Suite# 117, Wakefield, MA 01880
(800) 721-4711 toll free and (781) 577-1488 Local
Fax (781)694- 3511
Visit Us at www.nelimos.com

Travel Agent Registration Form
Please complete, print, sign this form and Fax it to (781)694- 3511 Attn: Billing Department

If you have questions or comments, please call 781- 267- 6086 Local
Please complete this form and Fax it to 781- 694- 3511 Attn: Travel Agent Sales

Travel Agent____________________________________________________________________________

Name ___________________________________________________________________________________

Telephone Number:___________________________________________ Ext: _______________________

Fax: _________________________________________ E-mail: ___________________________________

Website: _______________________________________________________________________________

Travel Agency: ___________________________________________________________________________

Company Name: _________________________________________________________________________

Street Address: _________________________________________________________________________

City: __________________________________________________________________________________

State (if applicable): _____________ ZIP Code: _______________ Country: ________________________

Certification

All of the information that I have provided on this form is correct to the best of my knowledge and I am authorized to submit this registration form.

I acknowledge and accept the terms and conditions posted on Northeastern Limousine's Web site at
www.nelimos.com/terms.htm.


_______________________________ _____________________________ _________________
Signature Print Your Name Date

NOTE: IF THIS TRANSMISSION IS RECEIVED IN ERROR PLEASE CALL Northeastern Limousine at (800) 721- 4711.