NAME: _________________________________________________ START DATE: _____________ TIME: _____________
COMPANY: _____________________________________________ END DATE: _____________ TIME: _____________
ADDRESS: _____________________________________________ PICKED UP _____ OR DELIVERED ______
CITY, STATE, ZIP: ________________________________________ SECURITY DEPOSIT PAID: $_____________________
PHONE: _____________________ CELL: ___________________ CARDHOLDER: ________________________________
EMAIL: _________________________________________________ CC #: ________________________________________
FAX: ________________________ EXP.: ______/______ CODE: __________________
____________________________________________________________________________________________________________
MACHINE / MODEL : RENTAL FEE: RET'D.
$ _____
____________________________________________________________________________________________________________
MACHINE / MODEL : RENTAL FEE: RET'D.
$ _____
____________________________________________________________________________________________________________
MACHINE / MODEL : RENTAL FEE: RET'D.
$ _____
____________________________________________________________________________________________________________
ACCESSORIES & SUPPLIES: QTY. PRICE: RET'D.
$ _____
____________________________________________________________________________________________________________
ACCESSORIES & SUPPLIES: QTY. PRICE: RET'D.
$ _____
____________________________________________________________________________________________________________
ACCESSORIES & SUPPLIES: QTY. PRICE: RET'D.
$ _____
____________________________________________________________________________________________________________
OTHER ITEM(S): QTY. PRICE: RET'D.
_______________________________________________________ _________ $___________ _____
_______________________________________________________ _________ $___________ _____
_______________________________________________________ _________ $___________ _____
____________________________________________________________________________________________________________
DELIVERY AND / OR SET-UP CHG: $____________
PICK-UP CHG: $____________
LATE FEE: $____________
6% SALES TAX: $____________
TOTAL: $_________
CUSTOMER SIGNATURE: __________________________________________________ DATE: ___________________
PARTY WORKS SIGNATURE: _______________________________________________ DATE: ___________________