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New Customer Form:
Corporations, LLCs, and Companies

*=Required fields. If you are not a corporation, LLC, or company,
please use the form for individuals or partnerships.

Contact Person at Your Company*
Rental Agent at Budget Video
Email Address of Contact Person*
Enter your name or the name of the appropriate person at your company. If you've already spoken with an agent at Budget Video, enter their name in the "Rental Agent" field.

Email addresses are never sold or shared and are only used by Budget Video.

Approximate value of equipment to be rented:*
 

PART 1 of 4: Company Information

Company Name*
Company Type:*
Federal Tax ID (FEIN)*
DBA (if applicable)
 
Year Started*
Incorporated in Which State?
 
Parent Company (if applicable)
Parent City, State
 
Business Description

For example, "Production Company", etc.
Business Web Site
 

Company Facebook

Like Us: facebook.com/BudgetVideo
Company Twitter

Follow Us: twitter.com/BudgetVideo
 

Phone
Fax
Mobile
 
*at least one phone number is required.

Permanent Address* (no P.O. Boxes)
 
City*
State*
Zip*
Country
 

Billing address same as physical address

Billing Address *
 
City*
State*
Zip*
Country
 


Require Purchase Orders
 
List persons authorized to place orders:

Enter Full Names, One Per Line.
 


PART 2 of 4: Officer Information

Name of President or Authorized Officer*
Position of Officer*
Driver's License Number*
State*
Issue Date
Expiration Date*
Date of Birth*
Social Security Number*
 

Officer's Email Address*

Email addresses are never sold or shared and are only used by Budget Video.
 


PART 3 of 4: Professional References

All applicants must provide references for a Cash And Carry account. A professional reference is a company or person who you do business with, preferably one in which you have established credit or someone you have worked with in the industry.

Reference 1

Full Name*
Company Affiliation*
 
Address*
 
City, State, Zip*
 
Phone*
Fax
Email Address
 

Reference 2

Full Name*
Company Affiliation*
 
Address*
 
City, State, Zip*
 
Phone*
Fax
Email Address
 

Reference 3

Full Name*
Company Affiliation*
 
Address*
 
City, State, Zip*
 
Phone*
Fax
Email Address
 


PART 4 of 4: Bank Reference

Name of Bank
Bank Contact Name
 
Branch Location
 
Bank Phone
Fax
Account Number
 

All information entered on this form is warranted to be true and is for the purpose of establishing an account at Budget Video Rentals. I authorize Budget Video Rentals to contact my references and verify the information in all fields.

Digital Signature: (Full Name)*