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
*
-
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
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
30
Minutes
AM
PM
AM/PM Option
End Date You Want To Return the Van
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
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
Should be Empty: