Sacramento Van Conversions, Inc.

CUSTOMER INFORMATION [Bold indicates required field]
Name:	Home Phone:	(916-555-1234)
Address:	Work Phone:	(916-555-1234)
Address: (Additional)	Cell Phone:	(916-555-1234)
City:	State:	Zip:
Employer:	Employer Phone:
E-Mail:	Fax:	(916-555-1234)

Credit Card#:

Exp. Date: -

Name on
Credit Card:

DRIVER INFORMATION
Name:		Driver's License:
Address:		Lic. Exp. Date:
Address: (Additional)		Drivers Date of Birth:	19
City:		State:	Zip:
Auto Insurance Co.		Auto Insurance Policy #
Agents Name:		Ins. Exp. Date
Agents Phone #:		Deductible:	$
Employer:		Employer Phone:
Social Security #:	(optional)
Has your drivers' license been suspended, revoked or refused during the past 3 years?
Have you been the driver in any accidents during the past 3 years?
Has any insurance Company ever cancelled or refused to write insurance for you?
* Please furnish details below for all YES answers above: I attest the above facts are true: (check here)

ADDITIONAL DRIVER INFORMATION
Name:		Driver's License:
Address:		Lic. Exp. Date:
Address (cont):		Drivers Date of Birth:	19
City:		State:	Zip:
Auto Insurance Co.		Auto Insurance Policy #
Agents Name:		Ins. Exp. Date
Agents Phone #:	(916-555-1234)	Deductible:	$
Employer:		Employer Phone:
Social Security #:	(optional)
Has your drivers' license been suspended, revoked or refused during the past 3 years?
Have you been the driver in any accidents during the past 3 years?
Has any insurance Company ever cancelled or refused to write insurance for you?
* Please furnish details below for all YES answers above: I attest the above facts are true: (check here)

Delivery / Pick-up Information (If needed) Additional Cost for Delivery & Pick-up
Contact Person:	Phone #:
Address:
City:	State:	ZIP:

	DELIVERY		PICK-UP
	Delivery Date:		Pick-up Date:
	Delivery Time:		Pick-up Time:
	Airport:		Airport:
	Airline:		Airline:
	Flight #:		Flight #:

Additional Information

My reason for renting this vehicle:

PLEASE NOTE: For "Insurance Replacement" choice above please indicate where vehicle is being worked on AND shop phone number:

Person in Wheelchair:

Person height in Wheelchair:

Wheelchair Type:

Do you need front passenger seat removed?

Do you need hand controls?

I have been trained in the use of driving aids and hand controls:

Dates Rental Van Needed > FROM: --- TO:

Web Design by AdventureIT2 Copyright © 2006 Sacramento Van Conversions, Inc. All rights reserved.

Web Design by AdventureIT2
Copyright © 2006 Sacramento Van Conversions, Inc. All rights reserved.