| PERSONAL INFORMATION |
| Name: |
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| Email
Address: |
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| Phone
Number: |
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| Cell Phone: |
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| Address: |
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| City: |
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| State: |
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| Zip
Code: |
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| How did you Hear about SRS: |
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| Promo Code: |
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| AUTO INSURANCE INFORMATION |
| Auto Insurance Carrier: |
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| Policy Number: |
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| Expiration Date: |
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Is your insurance
a
named only policy |
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| EMERGENCY CONTACT |
| Name: |
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| Phone: |
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| Relationship: |
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| ANNUAL MEMBERSHIP FEE |
| Cost |
$100 |
| PAYMENT INFORMATION |
| Credit Card Number: |
(Numbers Only) |
Name on Credit Card: |
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| Expiration Date: |
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CVC Code*: |
* (security code) |
| Billing Address |
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Billing City/ State/Zip |
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*Visa and MasterCard
In the signature box on the back of your Visa you should see a 16-digit credit card number followed by a special 3 digit code. This 3 digit code is your CVC.
*American Express
On the front of your card next to your main credit card number look for a 4 digit code. This 4 digit number is the Card Security Code. |
| SIGNATURES/HOLD HARMLESS AGREEMENT |
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Safe Ride Solutions Inc. and Customer each agree to defend, indemnify, and hold harmless the other party from and against all
claims, actions or causes of action, liabilities, including reasonable attorneys' fees, and costs arising from the defense of any
claim, action, cause of action or liabilities arising out of or resulting from any act taken or committed by Safe Ride Solutions, its
officers, agents, independent contractors or Customer pursuant to the performance of each party's obligations hereunder. Safe
Ride Solutions and Customer each agree to defend, indemnify, and hold harmless the other party for any claim, action, cause of
action, and liabilities which may be asserted by third parties arising out of the performance of either party's obligations pursuant to
this contract, except for the willful misconduct or gross negligence of the other party. Additionally the customer agrees to carry
adequate auto insurance coverage for their vehicle. |
| AUTOMATIC MEMBERSHIP RENEWAL |
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As a convience for our members Safe Ride Solutions offers automatic membership renewal. Use of this system insures your Safe Ride Solutions membership does not lapse. By selecting this option you authorize Safe Ride Solutions to automatically charge your annual renewal dues to your credit card each year at renewal time. You may cancel this arrangement anytime by contacting Safe Ride Solutions corporate office.
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| If you would like a copy of this form, please remember to Print a Copy of this form before you Click on Submit. |
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