Name: ______________________________ Address:____________________________ ____________________________ Home phone: ____________________ Work phone: ____________________ Cell phone or pager: ____________________ Email: ____________________ Vehicle Make, model, and year of vehicle: _______________ Vehicle license plate number: _______________ State of registration: ______________ Vehicle identification number (VIN): _________ Insurance company: _______________ Insurance policy number: _______________ Person Authorized to Drive (Borrower) Name: _______________ Address:____________________________ ____________________________ Home phone: ____________________ Work phone: ____________________ Cell phone or pager: ____________________ Email: ____________________ Driver's license number: _________________ Motor vehicle insurance company (if any): _______________ Insurance policy number (if any): _______________
Authorization and Consent of Vehicle Owner
I am the lawful owner of the vehicle indicated above. I give my authorization and consent for Borrower to use this vehicle as follows: Dates of use: _______________ Area in which vehicle may be used: _______________ Any restrictions or conditions on use: ________________________________________
I declare under penalty of perjury under the laws of the state of _____________ that the foregoing is true and correct.