Mobility Scooter Lease Application Form
First Name
Last Name
Date of Birth
Phone Number
Email Address
Residential Address
City
State/Province
ZIP/Postal Code
Preferred Scooter Type
3-Wheel
4-Wheel
Heavy Duty
Lease Duration
3 Months
6 Months
12 Months
Reason for Lease
Relevant Medical Conditions
Do you have insurance?
Yes
No
Additional Notes