New Customer Form

New Customer Form

Please select the service you are requesting.

Credit Card numbers are encrypted when
sent over the internet for your protection.

Checks or Money Orders can be made out to:

Bestway Group

Po Box 23 Janesville WI 53547

Please provide the following information for your Company

12 Month listing $5 a month billed once.....= $60
12 months + personal web page +Updating Capabilities & email address yourname@pilotcars.com---- $10 a month billed once....= $120
Company Name
Work Phone
Home Phone
FAX
Your Current Email address Your new email address can be	@pilotcars.com
Contact Name
Address
City, State, Zip
Rate Per Mile
Credit Card Type
Credit Card Number
Expiration Date
Name as it appears on card
High Pole Equipped


Confirm Credit Card Charge Amount $60 or $120