Download Form

You can download the form, print it, and fax it back to us:

> Adobe PDF

> Microsoft Word


 

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.

 

PART 1 of 4: Create a BudgetVideo.com Account

You'll be able to create quotes, review your rental history, and update your information.

First Name*
Middle Name
Last Name (Surname)*
If you've already spoken with an agent at Budget Video, enter their name in the "Rental Agent" field.

Email Address*
Rental Agent at Budget Video
Email addresses are never sold or shared and are only used by Budget Video.

Username (6-24 chars)*
Password*
Verify Password*



Approximate REPLACEMENT VALUE of the equipment being rented:*

 


PART 2 of 4: 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
 

You are the owner of this property. If not, fill in the following:
Property Owner/Landlord


 
Billing address same as physical address

Billing Address *
 
City*
State*
Zip*
Country
 

Web Site
 

Your Facebook

Like Us: facebook.com/BudgetVideo
Your Twitter

Follow Us: twitter.com/BudgetVideo
 


Application Type:*
 

This information is NOT STORED in our database and will only be used to verify your account.

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 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)*