Renter Information Form

First Name: Last Name:
Physical Address:
City: State: Zip Code:
Phone: Email Address:

Insurance Company: Agent:
Phone: Policy#: Deductible
Driver's License # Date of Birth: Exp Date
In the past 3 years has your driver's license been suspended, revoked or refused? YesNo
Have you ever been arrested for drug or alcohol related offenses? YesNo
Has any insurance company ever cancelled or refused to write insurance for you? YesNo
In the past 3 years have you been the driver at fault in any accidents? YesNo
Please explain:
Please explain:

I hereby affirm that the above information is true and correct. I authorize the above rental company to obtain any information from insurance agent, employer and credit information that might tend to aid in evaluating my responsibility, character, driving skills and credit.