510 N Street, SW, Suite 32, Washington, DC 20024 202-829-4444 800-328-2165
PHONE RENTAL AGREEMENT
Bill To:	Ship To:
Name:_______________________________________________	Name:_______________________________________________
Company:____________________________________________	Company:____________________________________________
Address:_____________________________________________	Address:_____________________________________________
City: ____________________________________	City: ____________________________________
State:_______________Zip Code:_____________	State:_______________Zip Code:_____________
Business Phone:_________________________________	Home Phone:__________________________________
Contact Name:___________________________________	Phone:_______________________________________
Rental Information	Phone Information
Date of Delivery:__________________ Date of Return:__________________	Model ______________________________________
Destination(s):_____________________________________________________	Serial Number: _______________________________
Billing / Payment Information (Please select card of use):	Optional Insurance Coverage * (Please select):
____ AMEX ____ MC ____ VISA ____ DINERS CLUB	____ YES ____ NO $2.00 per day / $150 Deductable or ____ Included
	* $350 fee for non-insured loss of GSM equipment
Cardholders Name:___________________________________________________________________
Credit Card Number:__________________________________________ Date of Exp._____________ CV#._______ (3 digit code)
Credit Card Billing Address (if different from above):___________________________________________________________
City:__________________________________ State:______________ Zip Code:_________________
Statement of Authorization
I hereby authorize C I Corporation to bill all rental and call charges to my credit card provided on this agreement form. I agree that a $500 authorization will be processed on the credit card provided at the time of this request. C I may require Customer to make a $500 deposit and reserves the right to either refund the deposit if Customer has maintained the account in good standing, or apply the deposit to any balance owed by Customer to C I Corporation.
I understand that C I C makes no warranty, express or implied, as to call quality or availability of each country’s cellular network(s). The quality of the cellular signal, especially inside buildings will vary. C I C is not liable for direct, special or consequential damages as a result of equipment, or the service provider.
I understand that I am fully responsible for all costs of damage, loss, or theft of the phone and equipment. Also, I am fully responsible for all call charges until service on that phone is deactivated by the service provider.
By signing this agreement, I acknowledge that I have read and understood this statement of authorization and authorize ICS to charge my credit card for any and all charges incurred under the terms of this agreement.
Cardholders Signature:_______________________________________________Date:__________________________
*Please fax order form to: 202-318-2503***
Email: info@cicorp.com