ORDER  FORM
CUSTOMER PLACING ORDER Customer  ID # Carrier Type
Contact Name:          
Contact Phone: (       )    
Express Auto Transport - Car Transporters
Email:      
Street:      
City:      
State:   Zip:   (800)405-0914   (513)870-6670   (513)870-6674 Fax
ORIGIN INFORMATION DESTINATION INFORMATION
Contact Name:     Contact Name:    
Contact Phone: (       )     Contact Phone: (       )    
Other Phone: (       )     Other Phone: (       )    
Other Phone: (       )     Other Phone: (       )    
Email:       Email:      
Street:       Street:      
City:       City:      
State:   Zip:   State:   Zip:  
VEHICLE INFORMATION VEHICLE READY DATE   /          /
Last 6 of your VIN       (Vehicle Identification Number) Year Make                               (ex: Ford, Chevy) Model                                   (Ex: Taurus, Camaro) Color Shipping Cost
                 
                 
Deposit (Refundable, See Agreement)  
VEHICLE RUNNING CONDITION Total Due Upon Delivery  
* VEHICLE MOVES UNDER IT'S OWN POWER
* VEHICLE HAS WORKING BRAKES   PAYMENT TYPE  (check one)
* VEHICLE CAN BE STEERED   * CASHIERS CHECK * DISCOVER
* VEHICLE HAS NO OTHER ISSUES   * VISA * AMERICAN EXPRESS
OTHER ISSUES:     * MASTER CARD * CHECK BY PHONE
        CREDIT CARD NUMBER
NAME ON CREDIT CARD
   
CARD HOLDER'S BILLING ADDRESS EXPIRATION DATE SEC
   
   
       
Card Holder's Signature (If Different than Customer):X          
                 
I have received, read, and understand the Shipping Agreement General Provisions of Express Auto Transport. I agree to the Shipping Agreement and I agree to pay the above amount. I understand that my deposit is refundable under the conditions in the Shipping Agreement. I understand that the COD amount must be paid upon receipt of the car, and that only Cash, Money Order, or Cashiers Checks are accepted.
Customer's Signature X           Date  
Mail To:  Express Auto Transport Fax To: 513-870-6674
9772 Princeton - Glendale Road
Cincinnati, Ohio 45246