ROCKET VIDEO
726
N. La Brea Ave. Hollywood, CA
90038
(323) 965-1100
RENTAL APPLICATION AND
AGREEMENT
NAME:
_______________________________________________________________
ADDRESS_____________________________________________________________
CITY:______________________________________STATE:_____ZIP:__________
HOME PHONE: ( )
________________________
WORK PHONE: ( ) ________________________
E-MAIL (if you wish to receive news of Rocket’s
Events) _____________________
CARD TYPE
(CHECK ONE) VISA_________ MASTERCARD _________
AMEX_________ DINERS ___________
CARD
NUMBER: _____________________________________EXP:______________
DRIVERS LICENSE #:________________________________
STATE:___________
HOW DID YOU HEAR ABOUT US?______________________________________
WHO ELSE MAY
RENT ON THIS
ACCOUNT?____________________________
______________________________________________________________________
(YOU ARE
RESPONSIBLE FOR EVERYONE WHO RENTS ON YOUR ACCOUNT)
PLEASE CHOOSE A MEMBERSHIP OPTION:
_____ ONE-YEAR
MEMBERSHIP (29.95 + TAX)
_____ LIFE
MEMBERSHIP (59.95 + TAX)
_____ NON-MEMBERSHIP
MEMBER RATE:
$2.76 + TAX FOR 2 DAY
RENTAL ($2.76 + TAX PER DAY LATE FEE)
NON-MEMBER RATE:
$3.69 + TAX FOR 2 DAY
RENTAL ($3.69 + TAX PER DAY LATE FEE)
I DECLARE THAT ALL INFORMATION SET FORTH
ABOVE IS TRUE AND CORRECT.
I UNDERSTAND AND AGREE TO ALL TERMS AND
CONDITIONS ON THE ACCOMPANYING MEMBERSHIP APPLICATION AND
RENTAL AGREEMENT (SEE BACK OF
SHEET)
SIGNATURE:
___________________________________________DATE: _________
Staff only: APPROVAL CODE: ________________ EMPLOYEE
NAME:________