28 Sunland Crescent
Mount Riverview NSW 2774
Phone: 0400 962 752
ABN 44 338 297 327
www.bluemountainscampertrailerhire.com.au
PERSONAL DETAILS (Please use block letters)
TITLE:
FAMILY NAME:
GIVEN NAME:
ADDRESS: STREET NAME & NUMBER
SUBURB:
STATE:
POSTCODE:
POSTAL ADDRESS:
SUBURB:
STATE:
POSTCODE;
DATE OF BIRTH:
/
DRIVERS LICENCE NO:
EMAIL ADDRESS:
/
HOME PHONE:
WORK PHONE:
MOBILE PHONE:
HIRE DETAILS (Please use block letters)
START HIRE TIME/DATE
EQUPIMENT CHECKED OK
FINISH HIRE TIME/DATE
EQUPIMENT CHECKED OK
Time_______ AM/PM
HIRER INITIAL ________
Time_______ AM/PM
BMCTH INITIAL ________
/
/
/
/
HIRER SIGNATURE ( I Have read Terms and Conditions which form part of this Agreement)
DATE:
/
CAMPER TRAILER HIRED:
/
TRAILER REGISTRATION
LICENSED DRIVER\HIRER DETAILS: (All persons towing the Camper Trailer for insurance purposes)
A copy of each licence must be attached
Driver/Hirer 1 – Full name on Licence & Signature
Licence No & State:
Name:
Have you ever been refused motor vehicle insurance
Expiry Date:
/
/
Date of Birth:
/
/
 Yes  No
Have you ever been convicted of an offence relating to driving a
motor vehicle under the influence of alcohol or drugs or driving with
X:
blood alcohol content equal to or great than the percentage from
I accept the terms and conditions of this Hire Agreement
time to time constituting an offence at law
Driver/Hirer 2 – Full name on Licence & Signature
Licence No & State:
Expiry Date:
/
Name:
/
 Yes  No
Date of Birth:
/
/
 Yes  No
Have you ever been refused motor vehicle insurance
Have you ever been convicted of an offence relating to driving a
motor vehicle under the influence of alcohol or drugs or driving with
X:
blood alcohol content equal to or great than the percentage from
I accept the terms and conditions of this Hire Agreement
time to time constituting an offence at law
Driver/Hirer 3 – Full name on Licence & Signature
Licence No & State:
Name:
Have you ever been refused motor vehicle insurance
Expiry Date:
/
/
 Yes  No
Date of Birth:
/
/
 Yes  No
Have you ever been convicted of an offence relating to driving a
motor vehicle under the influence of alcohol or drugs or driving with
X:
blood alcohol content equal to or great than the percentage from
I accept the terms and conditions of this Hire Agreement
time to time constituting an offence at law
 Yes  No
TOWING VEHICLE DETAILS (Hirer to ensure is suitable for Camper Trailer Hired)
TOW LIMIT FOR
VEHICLE MAKE:
MODEL:
BODY TYPE:
REGISTRATION:
VEHICLE:
CONTACT NEXT OF KIN/FAMILY
NAME/S:
ADDRESS (Street & Number)
HOME PHONE:
SUBURB:
WORK PHONE:
STATE:
POSTCODE:
MOBILE:
FOR INSURANCE PURPOSES AND OUR RECORDS PLEASE INDICATE YOUR PROPOSED ROUTE AND CONTIDITIONS?
 unsealed
 river

roads
crossings
beaches
 sand
 bush
 car
tracks
ferry or barge
FOR OUR RECORDS COULD YOU PLEASE DETAIL No. OF PASSENGERS
FOR OUR RECORDS, COULD YOU PLEASE INDICATE HOW YOU HEARD ABOUT OUR COMPANY