Escort Service Request Form

Escort Service Request Form
Customer Contact Information

Please Note: all fields are required on this page.
Name:*

PrefixFirst NameLast NameSuffix
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
File Upload:*

Please Note: form is not valid without government issued ID (Driver's License, Military ID, etc...)
Cancelof

Escort Details

Who are we escorting? -- if this is not a person escort; please skip to next page.
Name:

PrefixFirst NameMiddle NameLast NameSuffix
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
File Upload:

Please Note: form is not valid without government issued ID (Driver's License, Military ID, etc...)
Cancelof

Escort Details

What object are providing an escort for?
Description of the item:
Dimensions (please include length, width, height):
Weight (how much does the item weigh; Ibs. only):
Hazardous Cargo / Material?

Escort Details

Please Note: all information on this page is required.
Scheduled Departure Date & Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Scheduled Arrival Date & Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Number of Escorts Requested:*
Escort Departure Location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Escort Arrival Location:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list all preferred information (i.e., Route, Special Requests):
Our rates are listed below:
- $175.00 per escort (each escort can handle 6 - 12 vehicles depending on route).
- $50.00 per escort/per hour of overtime (starting 2 1/2 hours after requested arrival time).
- $50.00 per escort - for over 50 miles from the city limits.
- $50.00 per escort - for escorting on a holiday.
- $10.00 toll rate per escort - for each toll crossing with a procession.
Funeral Director Name:

First NameLast Name
Funeral Director's Signature:

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Customer's Signature:*

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Should be Empty: