Trading address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact

First Name

Last Name

Accounts department contact

First Name

Last Name

Contact name

First Name

Last Name

Contact name

First Name

Last Name

Contact

First Name

Last Name

Date

MM

DD

YYYY

I/We accept Electra's Terms and Conditions which are available on the link above. It is the responsibility of the hirer to provide adequate insurance cover to include all risks and subsequent loss of hire to equipment. *