| Fields with an asterisk (*) are required for the completion of this form. |
*Medallion Number |
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Period of Lease |
*From Date
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*To Date
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*Driver License (Hack) # |
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*Name of Lessee |
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Lessee's Phone # |
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*Name of Medallion Owner |
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*Workers Compensation
Insurance Carrier |
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*Workers Comp. Policy # |
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*Workers Comp. Expiration Date |
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>>VEHICLE INFORMATION: |
*Title Owner of Vehicle is: |
Medallion Owner |
Lessee |
Other |
*Vin |
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*License Plate Number |
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*Model Year
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*Make of Vehicle
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*Vehicle Insurance Carrier |
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*Vehicle Insurance Policy # |
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*Who is responsible for the Vehicle Maintenance? |
Medallion Owner |
Lessee |
Other |
*Coverage of Lease |
Shifts per week |
24 hours / 7 days per week |
How Many? |
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>>CHARGE TO LESSEE: |
Lease Price |
$
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Per
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$
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Per
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Security Deposit Other Charges (specify) |
$
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Per
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$
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Per
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Lessees Initial Payment |
$
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*Agent's or Owner's Name |
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*Agent's or Owner's License # |
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*Agent's or Owner's E-mail Address |
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Please enter the letters you see in the graphic below (required):
(letters are not case-sensitive)
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