First Name:                       Last Name: 

        Pick-Up:        01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00       Drop-Off:     01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2005 2006 2007 2008 2009 2010 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00

        Home Ph.:                         Cell Phone:    

        Car Class:    Economy Compact Intermediate Standard Mini-Van Convertible SUV                        Arrival Info (LAX):  

        Insurance:    Liability $13.00 CDW $8.95 Full Ins. $21.95 Personal Insurance w/verification    Birth date:    01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925

        Card Type:   VISA MASTERCARD AMERICAN EXPRESS DISCOVER/NOVUS            Card Number:   

        Expiration:   01 02 03 04 05 06 07 08 09 10 11 12 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018                                          Extras:    Baby Seat $10.00p/d Under 25 $10.00p/d Additional Driver $5.00p/d

       By checking this box I agree that I have read all of your disclaimer and agree to all terms and conditions                     mentioned therein.            

                  Terms an Agreements: By clicking on the RESERVE IT button, you confirm that you understand and accept our Rental Qualifications and Requirements. To review our Rental Qualifications and Requirements, click on the Rental Qualifications and Requirements link. Please note that at the time of rental you will need to present (1) a current driver's license and (2) a valid credit or charge card. LAX Discount Auto Rental will allow you to present certain debit/check cards in place of a credit or charge card; to determine whether your debit/check card will be accepted, please contact the lax discount office at 800-343-4833 (Note that if you have provided a debit/check card number above, then a confirmation of your reservation does not mean that the card is acceptable for the rental deposit. You must contact us by phone to determine if the card is acceptable.) Also at the time of rental, credit or charge cards must have available credit, and acceptable debit/check cards must have available funds, sufficient to pay the estimated amount of the rental charges plus an amount determined by Lax Discount Auto Rental to cover any incidental charges. As well any no show reservations that are not cancelled 24 hours prior to pick up date will be charged a $25.00 holding fee to the card authorized for the reservation.