NationalMobilityHire.com

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You have chosen:

• Powerchair
• 25 Weeks+
• South Region Delivery

£17.50 per week

If this is correct, please enter your details and select from the options available below. If this is incorrect, please go back and select another option.

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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.

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