Fort Lauderdale, FL

800-637-7577

Request Wheelchair Van Availability *

Renter Information

* First Name:

Middle Name:

* Last Name:

Date Of Birth:

Company:

Address:

City:

State:

Zip:

Country:

Driver's License #:

Exp. Date:

Home Phone:

() -

Work Phone:

() - x

Cell Phone:

() -

Fax:

() -

(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'

* First Name:

Middle Name:

* Last Name:

Address:

City:

State:

Zip:

Country:

Date of Birth:

Driver's License #:

License Exp.:

State License Issued:

Home Phone:

() -

Work Phone:

() - x

Cell Phone:

() -

Fax:

() -

Other Driver #2

* First Name:

Middle Name:

* Last Name:

Address:

City:

State:

Zip:

Country:

Date of Birth:

Driver's License #:

License Exp.:

State License Issued:

Home Phone:

() -

Work Phone:

() - x

Cell Phone:

() -

Fax:

() -

Other Driver #3

* First Name:

Middle Name:

* Last Name:

Address:

City:

State:

Zip:

Country:

Date of Birth:

Driver's License #:

License Exp.:

State License Issued:

Home Phone:

() -

Work Phone:

() - x

Cell Phone:

() -

Fax:

() -

Credit Card Information

Card Type:

Name On Card:

Card Number:

Expiration Date:

Vcode #:

Credit Card Billing Address

Same as renter

Address:

City:

State:

Zip:

Destination Information

Phone:

() -

Fax:

() -

* Delivery Date/Time:

@ :

Location of Delivery:

(if applicable)

* Return Date/Time:

@ :

Location of Return:

(if applicable)

Final Renters Destination:

(if applicable)

Airport Information

Airline Record Locator:

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. )