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Wheelchair Accessible Van Rental Form for Auto Mobility Sales in Florida

To request wheelchair van rentals online, complete the following form, print a copy for your records, and click the send button. A representative from our store in Florida will contact you soon.

If you prefer not to register online call us at 1-877-505-9067.

Contact Information

Renter's First Name
Renter's Last Name
Address
City State Zip
Phone
Fax
Email

Delivery & Return Information

Date of Delivery
Date of Return

Flight Travel Information

Arrival Airline
Arrival Time
Flight #
Departure Airline
Departure Time
Flight #

Renter/Driver's Insurance Information

Driver's Insurance Company
Insurance Policy #
Insurance Agent's Name
Does Policy Cover Rental Vehicle?


Insurance Agent's Phone #

We have reservations at:

Hotel Name
Phone
Local Contact

Accessibility Options

Number of Wheelchair Occupants
Number of non-disabled passengers (including driver)

Passenger Seat Removed?

Hand Controls Needed?
Wheelchair Traveler      Non-Ambulatory
Manual Folding Chair      Power Chair
Power Scooter
Other Special Needs

Emergency Contact Information

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