Rental Availability Request

Please fill out the form below to submit a rental availability request. We will make every effort to match your request; although please be aware that the date/time you request may not be available. Your request will be verified by phone.

Renters Information: (required) (All drivers must be 25 years of age or older)

Requested Reservation Date(s): (Please note that completion of this form does not confirm a rental reservation, but rather submits an availability inquiry request.)

Renters Information:
First Name:		Address:
Last Name:		Address:
Daytime Phone:		City:
Evening Phone:		State:
Date of Birth:		Zip:
Drivers License #:		Your Email:
Credit Card Information: Credit Card Information will be collectioned by AVM via Phone.
Insurance Information:
Insurance Company:		Insurance Company Phone:
Policy #:
Does Policy Cover Rental Vehicle?: Yes No
Additional Drive Information: (Must be included if primary driver is other than renter)
First Name:		Daytime Phone:
Last Name:		Evening Phone:
Date of Birth:
Drivers License #:

Optional Information: (Please Note: Rental service is not available at all locations. Please contact an AVM Representative for more information.)

Airport Information:
Arrival Airline:		Arrival Time:
Flight #:		Arrival Date:
Arriving Airport:
Departure Airline:		Departure Time:
Flight #:		Departure Date:
Departing Airport:
Billing Information: (To be used if an insurance company or other third party will be paying)
Billing Agent:		Address:
Company:
Phone:		City:
Fax:		State:
Claim/Purchase Order #:		Zip:
Name of Insured:

Additional Information:

Would you be interested in hand controls and/or a transfer seat? * Yes No

Will the individual in a wheelchair be the driver of the vehicle or a passenger?: Driver Passenger

Will you require a manual ramp or an automatic ramp?: Manual Automatic

(AVM recommends an automatic ramp if the driver of the vehicle is in a wheelchair and will be travelling alone.)
(* Hand controls and/or transfer seats not available at all locations.)

Please be advised that the completion of this form is not a rental reservation, but rather an availability request. An AVM Rental Representative will contact you to discuss each of the items on this form, confirm your reservation and obtain your billing information.

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