Sacramento Van Conversions, Inc.

WHEELCHAIR VAN RENTAL APPLICATION

SACRAMENTO VAN CONVERSIONS, INC.

All fields in BOLD are required.

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DRIVER INFORMATION

(ALL DRIVERS MUST BE PRESENT TO SIGN RENTAL CONTRACT UPON TRANSFER OF RENTAL VEHICLE)

NAME: ADDRESS: CITY:

STATE: ZIP CODE: HOME PHONE: CELL PHONE:

E-MAIL: (A confirmation number for your reservation will be emailed to this address)

DRIVER LICENSE #: LIC. EXP: Driver's Date of Birth 19

AUTO INS. COMPANY: AUTO INS. POLICY #: EXP:

INS. AGENT NAME: INS. PHONE #: DEDUCTIBLE: $

EMPLOYER: WORK PHONE: FAX:

Has your driver's license been suspended, revoked or refused during the past 3 years?

Have you been the driver in any accidents during the past 3 years?

Has any insurance company ever cancelled or refused to write insurance for you?

* Please furnish details below for all YES answers above:

I attest the above facts are true: (check here)

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ADDITIONAL DRIVER INFORMATION

(ALL DRIVERS MUST BE PRESENT TO SIGN RENTAL CONTRACT UPON TRANSFER OF RENTAL VEHICLE)

NAME: ADDRESS: CITY:

STATE: ZIP CODE: HOME PHONE: CELL PHONE:

DRIVER LICENSE #: LIC. EXP: Driver's Date of Birth 19

AUTO INS. COMPANY: AUTO INS. POLICY #: EXP:

INS. AGENT NAME: INS. PHONE #: DEDUCTIBLE: $

EMPLOYER: WORK PHONE: FAX:

Has your driver's license been suspended, revoked or refused during the past 3 years?

Have you been the driver in any accidents during the past 3 years?

Has any insurance company ever cancelled or refused to write insurance for you?

* Please furnish details below for all YES answers above:

I attest the above facts are true: (check here)

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BILLING INFORMATION - VISA, MASTERCARD AND DISCOVER ACCEPTED

CREDIT CARD#: EXP:: - NAME ON CREDIT CARD:

ADDRESS: CITY: STATE: ZIP CODE:

CONTACT PHONE: CELL PHONE:

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ADDITIONAL INFORMATION

PERSON IN WHEELCHAIR: HEIGHT WHILE IN WHEELCHAIR: WHEELCHAIR TYPE:

DO YOU NEED FRONT PASSENGER SEAT REMOVED? DO YOU NEED HAND CONTROLS?

I HAVE BEEN TRAINED IN THE USE OF DRIVING AIDS AND HAND CONTROLS (Please bring proof of certification)

REASON FOR RENTAL: FOR INS REPLACEMENT, NAME OF SHOP AND PHONE NUMBER WHERE YOUR VEHICLE IS BEING WORKED ON:

DATES RENTAL VAN NEEDED FROM: TO:

(Please Note: We are closed on Saturday and Sunday) _______________________________________________________________________________________________________________

AIRPORT/HOME DELIVERY & PICK-UP INFORMATION

(OPTIONAL) - ADDITIONAL COSTS APPLY - CALL FOR RATES

CONTACT PERSON: CONTACT PHONE#:

DELIVERY PICK-UP

AIRPORT NAME: AIRLINE: AIRPORT NAME: AIRLINE:

FLIGHT #: FLIGHT ARRIVAL TIME: FLIGHT#: FLIGHT DEPARTURE TIME:

HOME/OFFICE DELIVERY ADDRESS: HOME/OFFICE PICK-UP ADDRESS:
CITY/STATE/ZIP: CITY/STATE/ZIP:

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