ROSEBUD VIDEO STORE
DRIVER'S LICENCE NO.
CREDIT CARD (Check One)
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.
STORE USE ONLY
Customer ID Number__________________________________________________________________________
Driver's License Verified/Credit Card Authorized _____________________________________ (employee initials)
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