Rental Form

Los Angeles International Airport

5$ Off 2nd Scooter Per Day

After you fill out this rental form, we will contact you to go over details and availability before the order is completed. If you would like faster service and direct information on pricing please contact us by calling (562) 697-7725 or email us sales@ascooter4u.com, you can also visit us www.rentmobilityscooter.com

Are you a new or existing customer? *

I am a new customer
I am an existing customer
Not sure

Name *

First

Last

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone Number *

Secondary Phone Number

Please Type Your Hotel Name and Address *

Registered Hotel Guest Name:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Choose the equipment you need

How many scooters do you want to rent? *

Scooter Rider's Height *

Please enter rider's height. E.g. 5'10

Scooter Rider's Weight *

Please enter rider's weight in Lbs (pounds). E.g. 145

Delivery Date / Time *

Date

Time

Please select which date you want a scooter to be delivered and approx. time of your arrival to delivery place.

Return Date / Time *

Date

Time

Our rental return- Pickup timer is 7:00 AM. So select the return date accordingly. You won't be a charge for the day we pick up at 7:00 AM.

Special instructions (optional)

Name