NAME

STREET

CITY

STATE

ZIP CODE

HOME PHONE

CELL PHONE

E-MAIL ADDRESS

DRIVER'S LICENCE NO.

STATE

EXPIRATION DATE

CREDIT CARD (Check One) MASTERCARD VISA

NUMBER

EXPIRATION DATE

I heareby certify that the information is true and correct and authorize the store to cheak the information for accuracy. Customer assumes responsibility for any damage or loss of merchandise and for all rental and late fees accrued on membership account. Failure to return rental items within ten (10) days may cause membership to be revoked, credit card to be charged for value of files and/or replacement cost for rental items.

Signature:_________________________________________________ Date:___________________________

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STORE USE ONLY

Customer ID Number__________________________________________________________________________

Driver's License Verified/Credit Card Authorized _____________________________________ (employee initials)