Cleveland, OH

1-800-642-2042

Request Wheelchair Van Availability *

Renter Information

* First Name:

* Last Name:

Date Of Birth:

Company:

Address:

City:

State:

Zip:

Driver's License #:

Exp. Date:

Home Phone:

() -

Work Phone:

() - x

Cell Phone:

() -

(at least home phone, work phone, or cell phone is required)

* Email:

I would like to specify more drivers
Check here if there is more than 1 driver or if the primary driver is someone other than the renter

Other Driver #1
Primary Driver?	Yes No If the primary driver is someone other than the renter, select 'Yes'
Name:
Date of Birth:
Driver's License #:
License Exp.:
State License Issued:
Other Driver #2
Name:
Date of Birth:
Driver's License #:
License Exp.:
State License Issued:
Other Driver #3
Name:
Date of Birth:
Driver's License #:
License Exp.:
State License Issued:

Credit Card Information

Card Type:

Name On Card:

Card Number:

Expiration Date:

Vcode #:

Destination Information

Phone:

() -

Fax:

() -

* Delivery Date/Time:

@ :

Location of Delivery:

(if applicable)

* Return Date/Time:

@ :

Location of Return:

(if applicable)

Airport Information

Arrival Information

Airline:

Flight #:

Flight Time:

Departure Information

Airline:

Flight #:

Flight Time:

Your Current Auto Insurance Information

Must have own insured vehicle with comprehensive collision coverage which includes coverage for driving a rental

My Insurance Covers Rental Vehicles:

Yes No

Company:

Address:

City:

State:

Zip:

Phone:

() - x

Agent Name:

Agent Phone:

() - x

Policy #:

Expiration:

Vehicle Set Up

Seating For Passenger (front):

In Out

Request GPS:

Yes No
Not available in all locations. Additional cost applies.

Hand Controls:

Yes No

Spinner Knob:

Yes No

Number Of Wheelchairs:

Wheelchair Type:

Total Number Of People:

Other:

Power Chair/Scooter Rental Information

Power Chair

Scooter

Person's Height:

Person's Weight:

Any Other Additional Requests/Comments

How did you hear about us?

Comments:

( * Requests for reservations are not valid until you receive a confirmation. )

Cleveland, OH

1-800-642-2042

Request Wheelchair Van Availability *

Renter Information

Other Driver #1

Other Driver #2

Other Driver #3

Credit Card Information

Destination Information

Airport Information

Arrival Information

Departure Information

Your Current Auto Insurance Information

Vehicle Set Up

Power Chair/Scooter Rental Information

Any Other Additional Requests/Comments