Applicants Name: ______________________________Ph #: _______________________

Fax #_________________________ Cell #_______________________

Address: _______________________City: ______________State: ______Zip___________

Employer: ______________________ Ph#______________Position: __________________

Address: _______________________ City: _____________State: ______Zip___________

Auto Ins. Co: ____________________Agent: _______________Phone: _______________

Smoker____Non Smoker____

PERSONAL REFERENCE

Name: __________________Home Phone #______________Work Phone #_______________

Address: ___________________City: _________________State: _______Zip__________

TRIP INFORMATION

Depart: ____/____/____ Time: ____AM PM Return: ____/____/____Time: ____AM PM

MH size____ # In Party___ Adults___ Children____ Ages: _________House kits @ $ 35.00 ea. ______

Pick up City: __________________Drop-off City: __________________ Destination: ______________________________Est. Miles___________

Ever driven a Motor home Yes____ No____

Referral Source: _________________Special Request: ____________________

FLIGHT INFORMATION

Arrive____/____/____ Time: _____AM/PM Airport: __________Airline: _____________Flight # _________

Return____/____/____Time: _____AM/PM Airport: __________Airline: _____________Flight #

Hotel: ______________________

AUTHORIZED DRIVERS

# 1 Full Name: ____________________________Age: _____Birth Date: _____/_____/_____

License #: ______________________State: __________Exp. Date: _____/_____/_____

# 2 Full Name: ____________________________Age: _____Birth Date: ____/____/____

License #: ______________________State: __________Exp. Date: ____/____/____

The above information is true and correct to the best of my knowledge:

Applicants Signature: ____________________________

RESERVATION DEPOSIT

It is necessary for this authorization to be read and signed. Return by e-mail or fax to confirm the services to be charged to your credit card. Whether you are using a credit card or not, an open credit card authorization is taken for all rentals. Please have your credit card available at time of departure. Canyonlands will not charge your credit card unless damages are present when you return the RV or an accident occurs to cover the insurance deductible that over exceeds the

$ 500.00 Security Deposit, or other costs that exceed the security deposit relating to your RV rental, or excess mileage, gas, propane, or cleaning if the RV is not returned in a clean condition as you received it. Be aware that the reservation deposit of $ 300.00 is not refundable, if rental is canceled 30 days or less prior to departure date. All cancellations are charged $100.00 cancellation fee.

Credit Card Holder Name: _________________________Home Phone: _____________________

Address: ______________________________________ Work Phone: _____________________

City: _____________________State: _________________

I_____________________________, with my signature, as it appears on my credit card, authorize Canyonlands RV Rentals, Inc. to charge my credit card for the reservation deposit only, before departure, unless otherwise authorized by the customer.

___ AE ___Discover ___MC___Visa

Account # ______________________________Exp. Date: __________ Amount: $___________Reservation deposit

Applicants Signature______________________________Date: ____/____/____


Please print policy, complete and Fax to 1-435-674-3612