Rainbow Wheels Online Reservations System
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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

  Required *  
Arrival/Departure  
Arrival Month:*
Arrival Day:*
Arrival Year:*
Departure Month:*
Departure Day:*
Departure Year:*
   
  Credit Card Info (for security

please summit 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:
  

 

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.

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