Copyright 2012
Essex Rental & Sales
Center, Inc.
Rental Reservation Request Form
First name:
Last name:
Your email address:
Your phone number:
-

-

ext.
How would you like us to
contact you?:
Phone
email
What Rental Item(s) are
you interested in?
(Include size if applicable):
(mm/dd/yyyy)
Start Date:
Start Time:
ex 8 am or 9:30 am
Duration:
Minimum (4 Hours)
Day(s)
Enter Number of Days
Week(s)
Enter Number of Weeks
4-Week
Seasonal
Other
If Other Describe:
If you would like the equip.
delivered check here:
Enter delivery address below (if applicable):
Road/Street:
Town/City:
Zip Code:
(mm/dd/yyyy)
Date of Birth
Drivers License State
Drivers License Number
Address 1:
Address 2:
Town/City:
Zip Code:
Additional Comments:
Note:  Reservations are not valid until confirmed.  You will receive a
confirmation of the reservation via email or phone.  We process reservations
throughout the business day.  However, if you need immediate confirmation,
please call us at 802-878-5316 or 800-424-7300