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New Customer Form:
Individual Persons and Partnerships

*=Required fields. if you are not an individual or a partnership,
please use the form for corporations, LLCs, and companies.

FIRST Name*
M.I.
LAST Name*
Rental Agent at Budget Video
If you've already spoken with an agent at Budget Video,
enter their name in the "Rental Agent" field.
Approximate value of equipment to be rented:*
 

PART 1 of 3: Personal Information

DBA (if applicable)
 
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
 

Web Site
Email Address*

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

Your Facebook

Like Us: facebook.com/BudgetVideo
Your Twitter

Follow Us: twitter.com/BudgetVideo
 


Application Type:*
 
Current Employer*
Your Position
Years at this Job
Employer Phone
 

Driver's License Number*
State*
Issue Date
Expiration Date*
Date of Birth*
Social Security Number*
 

Where else have you rented equipment?
 


PART 2 of 3: 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 3 of 3: 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)*