Portable Room Application Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
-
Area Code
Phone Number
E-mail
example@example.com
Which Portable Room do you require?
Please Select
3.6 x 2.4
4.2 x 2.4
6.0 x 2.4
Next of Kin
*
First Name
Last Name
Next of Kin Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Next of Kin Mobile Number
*
-
Area Code
Phone Number
Next of kin date of birth
*
-
Month
-
Day
Year
Date
Please fill in 3 forms of ID
IRD or Passport No.
*
Car Registration
*
Drivers License Number
*
Delivery Address if different to the above:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Intended use of rental:
Preferred time frame for rental:
Any information in regards to site access which maybe useful:
How did you hear about us?
Please Select
Newspaper
Website
Word of Mouth
Submit
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