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Personal Information;
Fields marked with
*
are mandatory.
*
Name:
*
E-Mail:
*
Street:
*
Telephone:
*
Country:
--Select Country--
Australia
Canada
India
United States
United Kingdom
Singapore
Malaysia
Saudia Arabia
United Arab Emirates
South Africa
Others
*
State:
*
Postal Code:
*
City
Select the type of Mobility Rental
*
Mobility Rental:
Medical Scooter
Standard Scooter
Wheelchair
Power Chair
Length of Rental, Delivery & Pick-Up Information
*
Location Type:
(Hotel,Airport, etc.)
*
Street:
*
Country:
--Select Country--
Australia
Canada
India
United States
United Kingdom
Singapore
Malaysia
Saudia Arabia
United Arab Emirates
South Africa
Others
*
State:
*
Postal Code:
*
City:
*
Location Phone Number:
*
Number of Days :
# of Days
1
2
3
4
5
6
7
8
9
10
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12
13
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45
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60
*
Delivery Date:
Month
january
february
march
april
may
june
july
august
september
october
november
december
Date
1
2
3
4
5
6
7
8
9
10
11
12
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20
21
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23
24
25
26
27
28
29
30
31
Year
2012
2013
2014
2015
2016
Height:
5’0” – 5’7”
5’7” – 6’7”
*
Delivery Time:
Hour
1
2
3
4
5
6
7
8
9
10
11
12
Minute
00
15
30
45
AM
PM
Weight:
Under 300 lbs
300 lbs – 450 lbs
*
Pick-up Date:
Month
january
february
march
april
may
june
july
august
september
october
november
december
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2012
2013
2014
2015
2016
*
Pick-up Time:
Hour
1
2
3
4
5
6
7
8
9
10
11
12
Minute
00
15
30
45
AM
PM
If you want to rent more than (1) one scooter for longer than (7) seven days then please contact us at
customercare@scootaroundtheworld.com
or call (877) 726-9753
*
Payment Info :
--Select Card--
Visa
Mastercard
Discover
American Express
*
Rental Agreement: :
The client will use the equipment only for and in accordance with its intended use and pursuant to any instruction provided therewith. The Client agrees that if anyone is hurt or property damage during any participation within the rental period, the Client hereby releases all liability and waives his/her right to maintain lawsuit against Scooter World or its subsidiaries. Reasonable wear and tear is accepted. Rental will not be pro-rated, rentals exceeding the contract period shall revert to the daily, weekly, monthly rate, and exceeding the contract due date more than five days will be charged accordingly to rate payment on file.
I have read and agreed to the Rental Agreement.
Special Instructions
Special Instructions:
Scooter World, Inc.
Email:
jessie@scootaroundtheworld.com
Telephone:
U.S.A (877) 726-9753 [Toll Free]
(877) SCO-WRLD
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