Toll Free: 800-308-2503
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 Florida Eastern 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.  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 #        
Expiration Date:          
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:

 

 

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Discount Mobility USA
  6307 Hansel  Avenue * Orlando * Florida * 32809  
 Telephone: (800) 308-2503  * Office: (407) 438-8010 *  Fax: (407) 447-5312
Email: info@discountmobilityusa.com