The VW Camper Company LTD

Name of Hirer
Address (inc. postcode)
Tel. Home (or) Work
Tel Mobile
Contact email
Preferred camper	Isobel Martha Anna Delphi Any
Preferred dates	From		To
Likely destination (to help us with logistics)
No. of adults
No. of children
Driver Details
Name
DOB (dd/mm/yy)
Address (if different from above)
Date test passed
Driving Licence number
In the last five years have you had
any accidents or insurance claims?	Yes No
any convictions, including fixed penalty ?	Yes No
Please provide details of any endorsements : ie., offence code, date, fine points
Please provide details of any road accidents or insurance claims

© The VW Camper Company LTD 2012

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