All-States Auto Transport -- Order Form
This page must be completed and signed, as well as the 2 page Terms & Conditions.
Print This Page and Terms & Conditions and fax to 1-212-840-6707
Contact Information
Quote Number (if available):
Email Adress:
Primary Contact Person:
Primary Phone Number:
Requested pick-up date:
Your Vehicle Information
Year:
Make:
Model:
Type:    Sedan    SUV    RV    Pick-Up    Oversize (6'6"H x 17'L)    Truck    Convertible    Classic    Exotic    Van    Mini-Van    Boat    Motorcycle    Other
Running Condition?   Yes   No
Running with working...   Parking Brakes   Drive   Roll   Steer   Brake  
VIN#:Color:
Pick-Up Information
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell:
Delivery Information
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell:
Special Instructions
 
 
Payment Information
Quoted Price:
Cash discount price quoted reflects a 4% discount off the Regular Price, which will be charged to credit card payments.
Payment Option   Pay in Full with Credit Card   $150 Deposit, Balance on Delivery
Balance paid at delivery with cash, money order or cashiers check.
Type of Credit Card:    American Express    Discover/Novus    Mastercard    Visa  
Card Number:
Card Expiration Date:
Name on Card:
Card Billing Address:
Card Billing Zip Code:
Authorized Signature:
Agreement
I have read and agree to the terms in the Terms & Conditions of All-States Auto Transport.

Signature:
Date:

This page must be completed and signed, as well as the 2 page Terms & Conditions.
Print This Page and Terms & Conditions and fax to 1-212-840-6707