GREEN BIKE RENTAL APPLICATION FORM
HIRERS DETAILS
Title Mr    Mrs    Ms    Miss Other   
Surname First Name
    Middle Initials
   
Street Address
Suburb City
Phone(Home) Email
Phone(Mobile) ID Type/ Number
       
NEXT OF KIN      
Name Suburb
Street Address City
Telephone (##-###-####)  
LIABILITY
Hirer’s liability, not covered by insurance. The hirer accepts that the bike is hired at their own risk in respect to any loss or damage to the bike as a result of the hirer’s negligence and failure to abide by the conditions of hire. The hirer further understand that they will be liable for the first $250 of any insurance claim made by the Trust. This does not apply to any damage or loss of the bike resulting from fire, theft or attempted theft provided the entire terms and conditions of this agreement has been followed. I have read and understand the terms and conditions of hire as shown on this agreement and also agree to guarantee payment of the hire.
HIRER'S SIGNATURE
         
Hired From: (dd/mm/yyyy)   Returned On: (dd/mm/yyyy)
           
No Weeks:   @ $   Helmet, lock and key
         
Total to pay:      
         
PAYMENT RECEIVED: Cheque    Cash    EFTPOS    Credit Card
   

You have read and agreed to the terms and conditions of
the rental agreement and the liability clause of this agreement.
   
 
OFFICE USE ONLY      
Bike Number:   Pass
Helmet:   Pass
Lock & Key:   Pass
   Complimentary Kit    Backpack
Program Code  
   Total Payment $

New Zealand Green Bike Trust - PO Box 50122 PORIRUA CITY, Tel/Fax: 04 238 1641, www.nzgreenbikes.co.nz