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Wheelchair Minivan Rental Form

To request a van rental, complete the following form
and click the "submit" button.

We will contact you by phone within 4 business hours.
You may also call us toll free at 1-800-308-2503
Business hours: Monday through Friday 8:00am to 5:00pm Eastern Standard Time

NON U.S. RESIDENTS WELCOME

****Some ISP's block our e-mail answering your quote request.  If you do not get a response from us with-in 24 hours, please call us at 1-800-308-2503

Contact Information
Mr. Mrs. Ms.
Renter's Name (Required)
Address
City
State
Zip
Phone # Area code: Prefix: Number:
Preferred time of day to call: AM PM
Email  (Required)

Pickup & Return Information
(Monday-Friday, 8:30am-4:00pm, Orlando International Airport.)

Date of Pickup     (example: 06/08/2002)
Date of Return     (example: 06/14/2002)

Airline Travel Information

Arrival Airline
Arrival Time AM PM
Flight #
Departure Airline
Departure Time AM PM
Flight #

Driver's Insurance Information

Driver's Insurance Company
Insurance Policy #
Insurance Agent's Name
Insurance Agent's Phone # Area code: Prefix: Number:
Does Policy Cover Rental Vehicles? Yes No

Driver Information   (As it appears on valid drivers license)

Primary Driver
Driver's License #
State Exp. DOB
Additional Driver
Driver's License #
State Exp. DOB

Local Address while staying in Florida

Hotel/Resident Name
Address
City
State
Zip
Local Phone # Area code: Prefix: Number:
Will the vehicle be driven outside of Florida?    
Yes No

Method of Payment

Visa Master Card

Disability Information

Please describe disability in order for use to assist with
the correct transportation needs.


Accessibility Options
(Vehicles are not equipped to drive from a wheelchair. Driver must be able to
use a transfer seat)

Total Number of passengers (including driver)    
Number of Passengers in Wheelchair/Scooter    
Passenger Seat Removed      Yes No
Hand Controls     Yes No
Wheelchair Scooter     
Manufacturer     Model         
Occupants height from ground to top of hair while
sitting in wheelchair /scooter         
Other Special Needs         

 
Emergency Contact Information
Name
Relationship
Phone Area code: Prefix: Number: