Florida Rental Reservation

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Wheelchair accessible vans IN FLORIDA
Online Reservation

FOR RESERVATIONS CALL

(800) 910-VANS OR (407) 977-3799

OR FILL OUT FORM BELOW

Rental Reservation Request FORM

Please fill out this form as completely as possible as it will help us better serve you.
If you have any questions or would like a price quote on your rental,
please call us at 1-800-910-8267 or 407-977-3799

NOTE: This form does not finalize your rental, after this form is submitted to us we will call you or e-mail and confirm the information, we will also collect your credit card information.

Required *

Arrival/Departure
Arrival Month:*
Arrival Day:*
Arrival Year:*
Departure Month:*
Departure Day:*
Departure Year:*

Credit Card Info (for security please sumit info by phone)
Credit Card Type:
Name on Credit Card:
Credit Card Number:
Credit Card Expiration:

Renter Information
First Name:*
Middle Name:
Last Name:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Office Phone:
Fax:
Cell Phone:
Email Address:*
Driver License Number:
Driver License Exp:
Date of birth:

Second Driver
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Office Phone:
Fax:
Cell Phone:
Email Address:
Driver License Number:
Driver License Exp:
Date of birth:

Flight Information
Airport Arrival:
Airline Arrival:
Flight Number Arrival:
ETA Arrival:
Airport Departure:
Airline Departure:
Flight Number Departure:
ETA Departure:

Equipment needed
Passenger Chair (IN/OUT):
Passenger Seats:
Hand Controls:
Number of Wheelchairs:
Number of Passengers (total):
Type of Chair or Scooter:
Additional Equipment

Insurance Information
Insurance Company:
Insurance Agent:
Agents Phone:
Agent Fax:
Policy Number:
Policy Expiration:
Does Policy Cover Rental:

Staying At: