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First Name:

Last Name:

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Address:

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Employer:

Insured With:

Agent Name:

Agent's Phone Number:

Pickup Location:

Date Needed:

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Return Date:

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Catagory of Van you want to Rent:

How many Vans do you need?

Number of Passengers:

I want seats removed from 15 Passenger to make room for cargo :

Are you Tax Exempt?

Are you renting for a church?

Name of church:

Anything else we need to know? Or do you have a question or special request?