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Appendix D - Sample Courtesy Vehicle Check-Out Form Used by Higginsville Municipal Airport
Pages 87-90

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From page 87...
... Name: Address: City: State: Phone: Cell Phone: Driver's License Number: Expires: Auto Insurance Company: Policy Number: Expires: Agent's Name: Agent's Contact Information: Tail No. of Aircraft: Beginning Mileage: Ending Mileage: Visible damage to the vehicle prior to rental: Visible damage to the vehicle/or vehicle operational concerns upon return: The airport is pleased to furnish you with a Courtesy Vehicle while you are visiting.
From page 88...
... By signing this form, I agree to the terms for use of the Airport's Courtesy Vehicle. _________________________________________ ________________________ Signature Date Airport Courtesy Car Hold Harmless Agreement I/We,___________________________, agree to protect, defend, indemnify, save and keep harmless, the Airport against and from any and all claims, loss, cost, damage or expense, arising out of or from any accident or other occurrence while driving the airport courtesy vehicle causing injury to any person or property damage, including injury to myself/ourselves, and will comply with and perform all the requirements and provisions agreed to and required by the Airport.
From page 89...
... Sample Courtesy Vehicle Check-Out Form Used by Higginsville Municipal Airport D-3 Name of Company _________________________________________________ Signature Date ___________________________________ ____________________________________ Insurance Carrier Insurance Agent ___________________________________ ____________________________________ Policy # Phone #


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