CAR RENTAL FORM

This section is to be filled out by the car rental company:

Vehicle Check-out: _______________

Vehicle Due Back: _________________
Odometer Reading at Check-out: ________________ Check-in: _______________
______________________________________________________________________________

Name of Renter (as appears on license): _______________

Home Address: _______________________________
Date of Birth: ___________________
Phone Number: _________________
Driver’s License Number: __________________ State: ______
Expiry Date: _____________________

Do you have Auto Insurance? ❑ Yes ❑ No

Auto Insurance Company: ______________________ Policy Number: ___________

Mode of Payment: ❑ Cash ❑ Credit Card

If you checked Cash, please skip this section

Credit Card: ❑ VISA ❑ Master Card ❑ American Express ❑ Other: ______________

Credit Card Number: ______________ Security Code: ______________
Name on the Card: _______________ Expiry Date: ________________

Additional Driver? ❑ Yes ❑ No

Name of Renter (as appears on license): _______________

Home Address: _______________________________
Date of Birth: ___________________
Phone Number: _________________
Driver’s License Number: __________________ State: ______
Expiry Date: _____________________
Car Rental Amount: ❑ Daily ❑ Weekly $ ____________
Car Model: ______________ License Number: _____________
Car Type: ____________
Gas Tank Reading: ❑ Full ❑ Other _____________ %

TERMS AND CONDITIONS

The car renter should refill the gas tank upon return according to the gas tank reading
upon check-out. Failure to do so shall result in a penalty fee of $_______________. Only the
names registered in this form are allowed to drive the vehicle. The renter will be responsible for
all the car’s repairs, damages, replacements, lost keys, and/or lockouts while under the renter’s
use. Your auto insurance may fully or partially cover the damages to the vehicle. Communicate
with your insurance provider regarding coverage. The renter shall return the vehicle in good
condition at the same place where they got the vehicle.

Renter’s Signature: _________________ Date: ____________