application

500 Lake Avenue
Lancaster, NY 14086

716-686-9115

APPLICATION

Print the following form and mail to the above address after completion.

**Reservation Request**
**$250.00 deposit required to reserve a motorhome**
Unit Size Request:______________________		Approx. miles:_________________________
Travel Dates:_________________________		Car Insurance Agent:____________________
Pickup Date:___________ Time:__________		Phone:________________________________
Return Date:___________ Time:__________		Address:______________________________
Destination:___________________________		City/State/Zip:_________________________

**Personal Information**
Name:_______________________________		Personal Reference:____________________
Home Phone:__________________________		Reference Phone #:_____________________
Address:_____________________________		Personal Bank:________________________
City:________________________________		Checking Acc't #:______________________
State/Zip:_____________________________		Bank Phone#:_________________________
Birthday:_____________________________		Bank Address:________________________
Social Security #:______________________		City:________________________________
Employer:____________________________		State/Zip:_____________________________
Employer's Phone:______________________		Circle Card Type: Mastercard, Visa, American Exp., Discover
Employer's Address:____________________		Credit Card #:________________________
City:_________________________________		Exp. Date:____________________________
State/Zip:_____________________________		Driver' License #:______________________
Occupation Title:_______________________		State:__________ Exp. Date:____________

All information herein is considered confidential. I, the undersigned, give permission to Expedition Motorhome Rentals, Inc. to obtain whatever information is necessary from
the above sources to charge the card above $250.00 for the Reservation Deposit.

Signature of Applicant:_____________________________________

Date:_____________