Enrollment Profile—Master Rental Agreement**	ENROLLMENT STATUS	
		 New Enrollment	 Profile Update Wizard® Number (Required for Profile Update)	 	 	 	 	 	 	

PERSONAL INFORMATION		First Name		Last Name	
		     		     		
		Mailing Address 		City		State/Province	
		2121 Innovation Court		DePere		WI		
		ZIP/Postal Code		Country			
		54115		USA		     Home         X Business		
		Home Phone		Business Phone		Fax Number	
		    -     -     		    -     -     		    -     -       at  home or  work		
		Company Name		Avis Worldwide Discount (AWD) Number	
		Foth & Van Dyke		T838300 (If known)		
		E-mail Address 		Please do not send
me valuable Avis
benefits via e-mail.	
		     			
		Add your e-mail address to your profile, and we will send your rental receipts electronically.			
		Date of Birth (Month/Day/Year)		Driver’s License No.		Issuing State/Province		Issuing Country	
		   -    -     		     		  		   		

CREDIT CARD		Avis accepts many major credit cards as credit identification at the time of rental. An Avis honored credit card must be provided to enroll in and use Avis Preferred Service. A debit card can only be accepted on a Preferred profile as a method of payment if an alternate Avis honored charge card is also provided at time of enrollment. Avis does not accept prepaid cards on a Preferred profile.	
										
		#1	 American   
     Express®	 Discover®	 Sears®		Account Number		Expiration Date (Month/Year)	
			 Avis	 MasterCard®
	  Visa®		DO NOT USE THIS SEC		   -   		
										
		#2	 American   
     Express®	 Discover®	 Sears®		Account Number		Expiration Date (Month/Year)	
			 Avis	 MasterCard®
	  Visa®		DO NOT USE THIS SEC		   -   		

PROTECTION & SERVICES		You must choose “Accept” or “Decline” for each option.

After reading the Avis Master Rental Agreement Terms and Conditions, please select the optional protections and services you wish to purchase when using the Avis Master Rental Agreement. When you select an option, you will be provided that optional protection and/or service where it is available. Liability for any loss of or damage to our vehicle, or for injuries or damages to other people or property, or for personal accident and effects, may be covered by your personal insurance or credit card agreement or other coverage. You should check your policies or agreements for coverage details.	
			
			LDW	Loss Damage Waiver	 Accept	 Decline		
			PAI	Personal Accident Insurance	 Accept	 Decline		
			PEP	Personal Effects Protection	 Accept	 Decline		
			ALI	Additional Liability Insurance	 Accept	 Decline		
			GPS	Where2® GPS	 Accept	 Decline		
			FSO	Fuel Service Option	 Accept	 Decline		

VEHICLE CHOICE		Vehicle Class Preference: (choose one)	
		 Compact (Chevrolet Cobalt or similar)	 Standard (Ford Fusion or similar)	 Premium (Buick Lucerne or similar)	

	 Intermediate (Pontiac G6 or similar)	 Full-Size (Chevrolet Impala or similar)	 Luxury (Cadillac DTS or similar)	

GLOBAL		TO REQUEST AVIS PREFERRED SERVICE IN EUROPE, AUSTRALIA AND NEW ZEALAND PLEASE CHECK THE BOX BELOW.

 Yes, I want the information on this completed Avis Preferred Enrollment Profile to act also as my enrollment for rentals in Europe, Australia and New Zealand where the service is available. By selecting this option, I have read the applicable Terms and Conditions for those areas that are available at avis.com/terms or I have requested and received them from Avis and hereby agree that my initial Preferred rental transaction in Europe, Australia and New Zealand will constitute acceptance of all those Terms and Conditions applicable to the country of rental.	

SIGN YOUR NAME		As renter, I have read and agree with the Avis Master Rental Agreement Terms and Conditions. I understand the Loss Damage Waiver (LDW) provision and all other provisions in the Terms and Conditions, agree to be bound by them and waive any right to read and sign the Rental Agreement at time of rental.	
			
		SIGNATURE:		DATE:			
			Required for the Avis Master Rental Agreement (Preferred)				
								
		**Be sure to complete each item. Submitting an incomplete form may delay your enrollment. Processing for Avis Preferred membership will take approximately 2 weeks. You will receive your Avis Preferred card in the mail. Therefore, Preferred status may not be available for your next rental.

If you want to modify a particular rental in any way, stop at the Avis counter first. I have read and agreed to the Avis Master Rental Agreement Terms and Conditions, as well as on this profile.  I acknowledge that I have read and understand the HI, IN, CT, CA, NV, MD, KS, IL, IA, MO, NY, CO, LA, TX and VA Disclosure Notices and MN Consumer Protection Notice concerning the Loss Damage Waiver (LDW) option. I also acknowledge receipt of warning notices for rentals in DC, AZ and WA. I am waiving my right to receive and sign the notices at the time of rental to avoid delay of my Preferred Service rental transaction. I understand that all information on the form is subject to verification by Avis. Notice for Dade County, Florida: You must be provided with a road map with each rental. Your signature on this document acknowledges receipt of that map; therefore, you need not sign for it at time of rental.	
			
		Please print, sign and fax this to: 1-877-769-5787
AP-APP-6/09