Name *

First Name

Last Name

Mobile Number *

(###)

###

####

Alternate Number

(###)

###

####

Mobility Scooter Accessories (Excludes Es2)

Choose the accessories you would like to use(leave blank if accessories not wanted.

Canopy

Rear Basket

Cupholder

Would you like to add an Equipment Protection Plan(EPP)? *

We offer two levels of protection plans - MANUAL EQUIPMENT AND SCOOTERS. If EPP is purchased it must be purchased on all items. EPP (Manual Equipment) covers damage to the equipment while only being $5 per day. Customer is responsible for a $50 deductible . EPP does not cover loss or theft of the rental equipment. The rental cost is not applicable to the deductible. EPP (Electric Scooter/Electric Wheelchair) covers damage to the equipment while only being $15 per day. EPP does not cover loss or theft of the rental equipment. .If damage should occur during the rental period, the Customer is responsible for a $450 deductible. The rental cost is not applicable to the deductible. If EPP is declined, the Customer, or their representative, acknowledges that it is their responsibility to promptly notify Mobility Etc if the rental equipment is damaged, lost, or stolen and the Customer will assume all repair or replacement costs, whether caused through misuse, accident, or any other means. Declining EPP makes the Customer solely responsible for any repair costs outside of normal wear and tear during the rental period, including accessories (keys, chargers, baskets, canopies, cup holders, and spare battery packs).

Epp(Manual Equipment) ($5 per day) DOES NOT COVER ELETRIC SCOOTERS

EPP(Electric Scooter/Electric Wheelchair)($15 day) DOES NOT COVER MANUAL EQUIPMENT

NONE

Pick Up Date *

The day you wish to receive your rental

MM

DD

YYYY

Return Date *

The day you wish to return your rental

MM

DD

YYYY

Need Delivery And/Or Pickup *

Free In-Store Pick Up And Drop Off

$29.99 Drop Off In Orange County

$29.99 Return Delivery In Orange County

$59.98 Drop Off And Return Delivery In Orange County