Renter's Information Form
Please fill-out as much as possible
Renter's Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Renter's Phone Number
*
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Area Code
Phone Number
Renter's E-mail
Renter's Auto Insurance Company Name & Policy #
The insurance company that will be covering you and our van while renting
Renter's Insurance Agent's Name and phone #
Start Date You Want To Rent a Van
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Month
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Day
Year
Date
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Hour
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30
Minutes
AM
PM
AM/PM Option
End Date You Want To Return the Van
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Month
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Day
Year
Date
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2
3
4
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:
Hour
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30
Minutes
AM
PM
AM/PM Option
Click all that apply
Yes, I have rented from Handicap Van Rentals before
Yes, I have Full Coverage on my own vehicle
Yes, we will be driving more than 40 miles outside of Houston
Driver's license number(s) & state(s) of each person(s) driving. Please list any additional driver's information here including insurance if different than above and any other pertinent info
Submit
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