DELUXE CAR RENTAL, LLC

[215] 532-4709 / [646] 597-1900

First Name

Last Name

UNIT NUMBER

HOME ADDRESS

City

State

Country

Zip Code

Phone *

Date of Birth

MAKE MODEL

COLOR

VIN

TAG NUMBER

REPLACEMENT VEHICLE

COLORS

EMPLOYER

CITIES

Driver License #

EXP DATE:

STATE

SOCIAL SECURITY NUMBER

BIRTH DATE

CAR MODEL

VINS

TAG #

MILES IN

MILES OUT

DATE-TIME IN

DATE OUT

TOTAL DISTANCE

FREE MILES

EXCESS MILES

VEHICLE MUST NOT BE DRIVEN OUTSIDE _____________ MILE RADIUS. CUSTOMER IS ALLOWED _________ MILES FREE PER DAY. EXCESS MILES WILL BE CHARGED AN ADDITIONAL RATE OF ___________ PER MILE.

ADDITIONAL DRIVER

Full Name

Home Address

Valid Date

DRIVER LIC#

CUSTOMER INSURANCE COMPANY

INSURANCE COMPANY

COMPANY ADDRESS

RENTAL

DAYS

CDW PER

EST. MILE AGE

WEEKS

2ND DRIVER

TAX

AMOUNT PAID

ALL CHARGES SUBJECT TO FINAL AUDIT

GAS OUT

E 1/8 1/4 3/8 1/2 5/8 3/4 7/8 F

GAS IN

E 1/8 1/4 3/8 1/2 5/8 3/4 7/8 F

EXCESS MILE

OTHER CHARGES

GAS

MINUS CREDITS

TAXABLE CHARGES

TAXES

REFUND

TOTAL DUE

DEPOSIT

CUSTOMER OWES

CUSTOMER PAY ALL TICKETS FINES

DATE PAID FULL

YOU ACKNOWLEDGE THAT THE VEHICLE HAS NO DAMAGE EXCEPT:

BY SIGNING BELOW, AGREE TO ALL OF TE TERMS AND CONDITIONS OF THIS RENTAL AGREEMENT. YOUR SIGNATURE BELOW AUTHORIZES US TO PROCESS A CREDIT VOUCHER IN YOUR NAME FOR ALL RENTAL CHARGES DUE.

CUSTOMER’S SIGNATURE

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AGENT SIGNATURE

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2ND DRIVER SIGNATURE

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COLLISION DAMAGE WAVER[CDW]

________________By initialing here, you agree to purchase our CDW. Our damage waiver does not cover all instances of damage to the vehicle. There are exclusions. Subject to the conditions in paragraph 5, your responsibility for Physical Damage to the Vehicle is limited to $

________________By initialing here, you decline our Collision Damage Waiver. You agree to be responsible for all damage to, or loss of. the Vehicle.

REJECTION OF UNINSURED MOTORIST PROTECTION

Am rejecting uninsured motorist coverage under this rental or lease agreement, and any policy or insurance or self insurance issued under this agreement, for myself and all other passengers or this vehicle. Uninsured coverage protects me and other passengers in this vehicle for losses and damages suffered if injury is caused by t he negligence of a driver who d o e s - n o t h av e a n y insurance lo pay for losses or damages.

Your Signature

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NO DRIVERS UNDER 21

IN CASE OF ACCIDENT CALL POLICE & YOUR INSURANCE CO. THEN RENTAL OFFICE