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Additional options

*Indicates required information
 
24 Hour Breakdown Cover (+£2.50 p/w)   (Tick if required)
     
Folding Scooter Ramp Hire (+£7.50 p/w)   (Tick if required)
     
Walking Stick / Crutch Holder (+£5.00 p/w)   (Tick if required)
     
Oxygen tank holder
(+£5.00 p/w)		   (Tick if required)
     
Delivery
(Select one option)*		   NMH Accompanied** More info
Collect by Hirer (No Fee)
     
Collection
(Select one option)*		   NMH Accompanied** More info
Return by Hirer (No Fee)
**For more information on delivery and collection options, click on the "Delivery/Collection" button on the left menu.
 
  PERSONAL DETAILS
 
Rental start date*  
dd   mm   yyyy
   
     
Duration of rental*   Weeks
     
Additional Information  
 
Title*  
     
First Name*  
Surname*  
User Weight*  
     
Company Name  
     
Type of Property  
Address Line 1*  
Address Line 2  
Town*  
City  
County*  
Post Code*  
     
Contact Number*  
Fax Number  
     
Email Address*  
 

DELIVERY ADDRESS*

Use same address as above
 Use address below
 
Address Line 1  
Address Line 2  
Town  
City  
County  
Post Code  
     
Contact Number  
 

By checking this box, the hirer agrees to the Terms and Conditions of hire.

 
   
 
 
 
 
 
 

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© National Mobility Hire (NMH) 2007.

*Map for illustrative purposes only, please see "Delivery" or contact us for a more accurate delivery radius.