deposit form

Billing Information

First Name:

Last Name:

Home Address:

Address (cont.):

City:

State:

Zip:

Country:

Phone:

Email:

Driver's License & Insurance Information

Driver's License:

Drivers License State:

Driver's License Exp:

Insured By:

Policy Number:

Payment Information

Name on Card:

Credit Card #:

Credit Card:

Expiration Date:

CVV2 # :

What is CVV2?

How did you hear about us?

Comments:

Rental Information

Rental Period:

From:

Time:

(e.g., 10:30 AM)

To:

Time:

(e.g., 11:25 PM)

Add a Garmin Navigation system at $10 a day

I would like the Unlimited Miles option.

By entering my initials into this box, I am acknowleging my deposit is non-refundable and adhere to the policies of Bedford Auto and Van Rentals.

Please be aware of your requested pickup and return times on this form! Rental charges will start and end on those specific dates and times. By entering my initials into this box, I am acknowleging my deposit is non-refundable and adhere to the policies of Bedford Auto Rentals.

"Once unlimited mileage is chosen, you will adhere to that mileage option". Please do your mileage math before choosing. No adjustments will be made at end of rental term

Please be aware before doing so.

Vehicle Type:	Qty:	Unit Price:	Price:
Deposit		$

		Subtotal: