ROSEBUD VIDEO STORE
MEMBERSHIP APPLICATION

 

NAME

STREET CITY

STATE ZIP CODE

HOME PHONE CELL PHONE

E-MAIL ADDRESS

DRIVER'S LICENCE NO. STATE

EXPIRATION DATE

CREDIT CARD (Check One) MASTERCARD VISA

NUMBER EXPIRATION DATE

I heareby certify that the information is true and correct and authorize the store to cheak the information for accuracy. Customer assumes responsibility for any damage or loss of merchandise and for all rental and late fees accrued on membership account. Failure to return rental items within ten (10) days may cause membership to be revoked, credit card to be charged for value of files and/or replacement cost for rental items.

Signature:_________________________________________________ Date:___________________________

STORE USE ONLY

Customer ID Number__________________________________________________________________________

Driver's License Verified/Credit Card Authorized ___________________________ (employee initials)

Back to Membership Page