*Company Name


* Name

* Address

* City

* State

* Zip Code

* Telephone (no dashes please)

* Email Address

Web Site

* Year Business Established


How did you hear about Broadcast Rentals?


To be completed for a CORPORATION; Tax ID #:


To be completed for a SOLE PROPRIETOR or PARTNERSHIP:
Social Security Number (no dashes please)

Home Telephone Number (no dashes please)

Drivers License #

State Issuing Drivers License

Drivers License Expiration Date



* BANK REFERENCE

* Bank

* Account #



* TRADE/CREDIT REFERENCES

* CREDIT CARD

* Account Number on card (no spaces please)

* V code (last three digits on the back of the card)

* Type of Card

* Name as it appears on the Card

* Expiration Date

* Mailing Address for Credit Card (Where your statements are sent to)
* Address

* City

* State

* Zip Code



INSURANCE

Broadcast Rentals, Inc. requires that a Certificate of Insurance naming us as Loss Payee be on file with us at least 24 business hours prior to the release of any equipment. The Certificate must cover equipment the total time the equipment is rented including its shipment by common carrier, if applicable. The rental period will continue until the equipment has been returned or repaired. The value of the equipment shall be the current manufacturer's list price at the time of loss plus shipping and taxes when applicable. A Loss/Damage waiver can be provided for an additional charge.

Insurance Carrier

Broker/Agent's Name

Phone

Address

City

State

Zip Code


Check box if you do not currently carry insurance coverage. Broadcast Rentals will charge for a Loss/Damage waiver at an additional charge.

PAYMENT TERMS AND CONDITIONS

Terms are COD except where an approved credit relationship has been established. Terms are net 30 days on established credit accounts. A service charge of 1.5% per month (18% per year) will be levied on all past due accounts. Should Broadcast Rentals, Inc. need to take action to collect any money due, Broadcast Rentals, Inc. shall be entitled to attorney's fees and costs and interest at 18% per annum from the date the money is first due. Should any dispute arise between parties, the dispute shall be resolved based upon Arizona law and be under the jurisdiction of the Arizona courts.

Check the following two boxes to complete your application:

I have read and agree to the insurance and payment terms and conditions. I authorize Broadcast Rentals, Inc. to check the applicant's credit history with the references given. In consideration of the extension of credit terms, the undersigned severally and/or collectively do personally guarantee the payment of all charges made by and/or on behalf of the applicants.

I have read the Rental Terms and Conditions and agree to the policies as outlined by Broadcast Rentals, Inc.