Once completed, this form must be printed, signed and then submitted to the appropriate City of Lewisville department along with any required fees.
VIDEO LOAN / APPLICATION FORM
Health Division
151 W. Church Street, Lewisville, Texas 75029-9002
Tel: (972) 219-3480 Fax: (972) 219-3772



ONLY A STATE CERTIFIED MANAGER/OWNER MAY RENT THE VIDEO
(A copy of state license and drivers license is required)


Place of Employment:
Address:
Work Number
Name:
Home Address:
City, State, Zip:
Home #:
TX DL #:


Videos are available to the City of Lewisville Food Establishment and their employees. A seventy-five dollar ($75.00) refundable deposit is required. If the video/DVD is not returned within twenty-four (24) hours, a late fee of five dollars ($5.00) shall be administered per day for up to ten (10) days. After ten (10) days the deposit fee shall be forfeited to the City of Lewisville. If the videotape/DVD is lost, stolen, or damaged, the deposit is automatically forfeited. This video is copyrighted, and may NOT be copied without express written permission from the publisher.

I have read and understand the above information and agree to abide by the terms.

**DEPOSIT WILL BE FORFEITED AFTER TEN (10) DAYS FROM RETURN DATE**

Signature:
Date:
Printed Name:



Below for Office Use Only
Rental Information
Rental Information

English DVD # Spanish Video #
Deposit: $ Cash        Check #
Date Issued: Video Return Date:        

Return Information

Date Video & Deposit Returned:Late Fee: $Employee:
Deposit Returned To:

Signature: