Agreement Form – 619 Rent A Car

619 Rent A Car Agreement Form

01 Customer information

Last name

First name

Home address

City

State

Zip

Home phone

Business phone

Employer

Employer city

Employer state

Driver's license no.

License state

License exp. date

Date of birth

DL Driver's license upload

Upload a clear photo or scan of the front of your driver's license (JPG, PNG, or PDF, up to 8 MB). *

02 Additional driver (optional)

Last name

First name

Address

City

State

Zip

Driver's license no.

License exp. date

Date of birth

03 Customer's insurance company

Insurance company

Phone

Policy number

Agent phone

04 Vehicle

Unit number

Make / model

Color

VIN

Tag number

Date out

Time out

Date due in

Time due in

Miles out

Miles in

Total miles

05 Rental rates & terms

Day rate ($)

Week rate ($)

Month rate ($)

Hourly rate ($)

Free miles included

Miles free per day

Mile radius limit

Excess mile rate ($/mi)

2nd driver fee ($)

Loss damage waiver ($)

06 Renters Collision Protection (RCP)

Renters Collision Protection (RCP) covers collision damage to this vehicle up to $20,000 with a $250 deductible, for a daily fee, as long as the contract terms aren't violated. RCP is non-refundable once purchased, even if the vehicle is returned early.

Decision

I purchase RCP coverage I decline RCP coverage

RCP rate per day ($, if purchased)

07 Rental return / final charges (completed at return, optional at booking)

Gas out

Gas in

Vehicle has no damage except

Excess miles charge ($)

Other charges ($)

Gas charge ($)

Minus credits ($)

Taxable charges ($)

Tax ($)

Total due ($)

Deposit ($)

Refund ($)

Customer owes ($)

08 Signatures

RCP decision signature *

Sign to confirm the RCP choice you made above.

2nd driver signature

Required only if you listed an additional driver above.

Customer signature — final agreement *

By signing, you agree to all terms and conditions of this rental agreement and authorize charges to the card on file.

619 Rent A Car Agreement Form

Complete your rental contract

RCP decision signature *

2nd driver signature

Customer signature — final agreement *

Agreement submitted