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First

M.I.

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Last

*

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City

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State

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Zip Code

City

State

Zip Code

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Primary Phone

Secondary Phone

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e-mail

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Request 4 Digit PIN Number
(for system reservations & fueling)

*
Date of Birth

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Expiration Date

*# Of Moving Violations (last 3 yrs)

How many vehicles do you own?
0 1 2 more than 2

* Do You have A Valid Credit Card? (debit/check cards not accepted)
Visa Master Card none

How Would You Like To Pay For Your Monthly Bill?
choose one Credit Card Check

Where Did You Hear About Car To Go?
choose one newspaper television internet radio/ KSPN radio/ KSNO radio/ KKCH city sponsored event friend current member mailer other Other:

By submitting this application, I verify all statements above are true to the best of my knowledge. I authorize Car To Go's insurers and their agents to check my driving record and insurance score. I understand that this information may be retained by Car To Go's insurers and/or their agents whether or not my application is approved. I agree to be bound to this application and understand that failure to disclose violations and accidents will cause automatic rejection of this application. I understand that this application and all of the above consumer reports will be used to determine my acceptance into Car To Go and that my application does not guarantee acceptance.