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©1975 - Keller Communications Inc.
Rental Request Form
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
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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!!!
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Keller Communications Inc.