Keller Communications Inc. ClearCall

Company Name:

First Name:

Last Name:

Phone:

Ext:

Email:

Billing Address:

City:

State:

Zip:

Contact Number:

Pick Up Date:

Return Date:

Number Of Radios:

Number Of Headsets:

Number Of Speaker Mics:

Number Of Channels Needed:

Choose Location Radios Will Be Used:

Other Location Not Specified In List Above:

Additional Comments:

Enter The Security Code

Initial

Any Rental Equipment Not Returned On The Agreed Return Date Will Be
Charged A Daily Rate Until Equipment Is Returned At The Agreed Contract Daily Rate. Any Equipment Lost Or Damaged Will Be Your Responsibility And Be Repaired Or Replaced At Your Expense.

<<< I understand my Responsibilities mentioned below!!!

0155234
Secuity Code