Master Rental Agreement - Enrolment Form and Profile

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REQUIRED INFORMATION
ASSOCIATION MEMBER
NRMA/RACQ/RACV Seniors Australian Medical Association Other Name of Association ____________________________________________
Membership Number ______________________________________________
FREQUENT TRAVELLER PROGRAM
(Choose one only)
Master Rental Agreement - Enrolment Form and Profile
Please use block letters
RapidRez Number (if applicable) ___________________________________________ Title Mr. Ms. Mrs. Miss Other
Surname _______________________________________________________________ First Name _______________________________________ Middle Initial
PERSONAL INFORMATION
Budget Customer Discount Number (BCD)
Company Name (if applicable) _______________________________________________________ (if applicable)
________________________
Company Address (if applicable) ________________________________________ Suburb _________________________ State __________ Postcode ______________
Home Address _______________________________________________________ Suburb _________________________ State __________ Postcode ______________
If PO Box given as a mailing address, full address is also required _______________________________________________________________________________________
Suburb _________________________ State __________ Postcode ___________ Preferred Mailing Address Home Company
Email Yes, send me Budget email specials Email Address _______________________________________________________________________________________________
By including your email address, you consent to receiving all notices under the Budget Fastbreak Service (including amendments to the Terms and Conditions applicable to the Service) by email.
Please complete the membership number for the frequent traveller program you wish to be credited for qualifying Budget rentals. Please include alpha prefix.
Qantas Frequent Flyer Airpoints (Air New Zealand) Mileage Plus (United Airlines) FlyBuys Australia
Other _______________________________________________ Membership Number __________________________________________________
CHARGE CARD BILLING INFORMATION
The following amounts will be debited to your nominated charge card below: (1) all Budget rental charges and fees in relation to the Budget Fastbreak Service at the time of rental; and (2) all tolls and fees
after they are incurred or notified to RMS by a toll road operator (see Section 8 below).
Type of card: Diners Club MasterCard Amex Visa Budget
Primary Card Number ________________________________________________________________________________________________ Expiry Date MTH I YR
Alternative Card Number ________________________________________________________________________________________________ Expiry Date MTH I YR
Note: Cash, cheques, debit cards and vouchers cannot be used for this Service.
If you do not already hold a Budget charge card and you wish to have: (1) your Budget rental charges and fees debited to the Company’s account with Budget
above and (2) Your tolls and fees debited to the Company’s account with RMS above (see Section 8 below), please ensure this section is signed by someone of
authority in the Company other than you.
I HEREBY AUTHORISE THE ABOVE APPLICANT TO BE ISSUED WITH A BUDGET CHARGE CARD LINKED TO THE COMPANY ACCOUNT NO.: BU869 ..........................................................
AND I AUTHORISE (1) ALL RENTAL CHARGES, FEES, COSTS AND AMOUNTS INCURRED BY THE APPLICANT (INCLUDING FOR THE OPTIONAL SERVICES/COVERAGES ‘ACCEPTED’
BELOW) TO BE DEBITED TO THAT ACCOUNT AND (2) ALL TOLLS AND FEES TO BE DEBITED TO THE COMPANY’S ACCOUNT WITH RMS (SEE SECTION 8 BELOW).
Name ___________________________________________ Signature 8 _________________________________ Position _______________________________________
OPTIONAL SERVICES/COVERAGES
Please read the applicable sections of the attached Budget Fastbreak Service Terms and Conditions booklet before completing this part of the Enrolment Form.
The information below is a guide only and is subject to those Terms and Conditions. Charges and options for services and coverages (in this
form, each a ‘service’) vary by country and are subject to change without notice. Please check the Budget website at: www.budget.com.au for
all current charges and terms and conditions applicable to a service at the time of rental.
Loss/Collision Damage Waiver
Limits your financial responsibility for loss or damage to the Budget vehicle and in some countries third party property damage or injury (if you
comply with the Budget Rental Agreement). In some cases an excess amount is payable. May not be available from all Budget locations.
It is included in most rates in Australia. Known as:
• Motor vehicle Insurance (MVI) (in New Zealand) (compulsory for a renter not domiciled in NZ) • Collision Damage Waiver (CDW) (in Europe) •
Loss Damage Waiver (LDW) (in USA/Canada)
The following services are available at selected locations in Australia:
Excess Reduction (ER)
In Australia, ER reduces your excess amount (see above section). Varies by age of renter, location, type of vehicle and rate. Note: ER does not
cover certain loss or damage.
Portable GPS
Yes, send me electronic receipts
Daytime Phone ____________________________________________ Driver’s Licence Number ________________________________ Date of Birth_____/_____/_____
You must hold a current licence (not being a learner’s licence or provisional licence) and have been licensed to drive for at least 12 consecutive months. note: if your overseas driver’s licence is not in
English, you must forward a copy of your international Driver’s Permit to Budget.
Please Initial
IMPORTANT NOTE: If you do not initial the ‘Accept’ or ‘Decline’ boxes for a service above, we will record ‘Decline’ in our records for that service.
You will, therefore, not have the benefit of such service and may be responsible for all loss or damage to a vehicle depending on the terms and
conditions of the Budget Rental Agreement in the country where the rental takes place.
ConTinuE ovER
CT9006A
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Accept
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Accept
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Accept
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Decline
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Decline
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Decline

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CAR GROUP PREFERENCE
X - Economy - manual/air-con
A - Compact - manual/air-con
B - Compact - auto/air-con
C - Intermediate - auto/air-con
D - Standard - auto/air-con
E - Full Size - auto/air-con
(Select One Only)
ACKNOWLEDGEMENT, AGREEMENTS, PRIVACY CONSENTS AND AUTHORISATION
P - Full Size Premium - auto/air-con
F - Full Size Wagon - auto/air-con
G - Premium - auto/air-con
H - Luxury - auto/air-con
V - Full Size Van - auto/air-con
By signing below:
1. you acknowledge that you have read and understood this form and the Budget Fastbreak Service Terms and Conditions attached to this form (Budget
Fastbreak Service Terms and Conditions);
2. you agree to be bound by the Budget Fastbreak Service Terms and Conditions as amended from time to time and as located on the Budget website, including:
(a) that you are liable for the loss of and all damage to the Vehicle unless this liability is reduced (see above);
(b) that, depending on the country of rental, you are always liable for the Excess Amount (and additional charges) and certain damage to the vehicle;
(c) (Australia only) the ‘RMS E-Toll Facility Terms and Conditions for the Budget Fastbreak Service’ (including the obligation to pay to Roads and Maritime
Services ABN 76 236 371 088 (RMS) the RMS service fee when you use an Australian toll road in addition to payment of the applicable tolls) as set
out in the Budget Fastbreak Service Terms and Conditions;
(d) the applicable Budget Privacy notices and policies;
(e) the ‘RMS Privacy Consent and Agreement for the Budget Fastbreak Service’; and
(f) those services and coverages above which are included or which you have accepted by initialling,
each as set out in the Budget Fastbreak Service Terms and Conditions;
3. you consent to Budget (as defined in the ‘Australian Terms and Conditions’ of the Budget Fastbreak Service Terms and Conditions) and RMS disclosing your
information to entities located outside Australia for the purposes set out in the ‘Budget Australia Privacy Notice’ and the ‘RMS Privacy Consent and Agreement
for the Budget Fastbreak Service’ respectively (each set out in the Budget Fastbreak Service Terms and Conditions), on the basis that neither Budget nor RMS
is required to ensure that any overseas recipient complies with Australian privacy laws; and
4. you authorise:
(a) Budget to debit all rental charges, fees, costs and amounts; and
(b) RMS to debit all tolls and fees,
to your nominated charge card above.
Tick this box if you do not want Budget to use your information to send you details about products and services which are provided by Budget or any of its related companies, licensees and program partners.
Signature 8 ______________________________________________________________________________________ Date ___________________________________
Print Name ______________________________________________________________________________________
Send this completed form to:
Budget Fastbreak
Reply Paid 79040
MASCOT NSW 2020
or
Fax: 1800 006 476
Any questions, please contact:
Email: fastbreak@budget.com.au
Tel: 1800 150 278
Master Rental Agreement - Enrolment Form and Profile (Page 2)
Budget Rent a Car, Level 2, 15 Bourke Road, Mascot, NSW 2020. Fastbreak Helpline 1800 150 278. Facsimile 1800 006 476.
Budget Rent a Car Australia Pty Ltd - ABN 89 007 348 021