Private Clients - Service Request Form Please fill in the form as much as possible so we may provide you with an accurate quote and availability for your trip. You are always welcome to call us at (718) 252-5555 or (800) 244-2428 and one of our friendly staff members will gladly assist you with a reservation or answer any questions you may have. Click the "Submit" button and our representative will get back to you shortly. SERVICE REQUEST FORM PASSENGER INFORMATION *First Name: *Last Name: Date of Birth: Example: 04/12/1955 Email: *Home Phone: Example: (212)345-6789 Cell Phone: Example: (212)345-6789 Equipment Needs: Standard Wheelchair Reclining Wheelchair Extra Wide Wheelchair Motorized Wheelchair Stretcher Oxygen Tank(s) Equipment: Select One Your Own Must Be Provided Passenger Weight in Lbs.: Select One 100-150 151-200 201-250 251-300 301-350 350 and above Patient needs assistance to transfer into the travel equipment: Yes No TRIP INFORMATION Trip Date: Example: 12/3/2008 Trip Time: Example: 09:00 AM Return Date: Example: 12/3/2008 Return Time: Example: 05:00 PM Pickup Address Address 1: Address2: City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip Code: Phone: Example: (212)345-6789 Wheelchair Accessible Building/Home: Yes No Stairs (Passenger Must Be Carried Up/Down): Yes No Number of Steps: Number of Flights: Destination Address Address 1: Address2: City: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip Code: Phone: Example: (212)345-6789 Wheelchair Accessible Building/Home: Yes No Stairs (Passenger Must Be Carried Up/Down): Yes No Number of Steps: Number of Flights: Driver should to wait at destination: Yes No Estimate Number of Hours: PAYMENT INFORMATION First Name: Last Name: Address1: Address2: City: State: Select State" Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip Code: Phone: Example: (212)345-6789 Payment Method: (Valid credit card is required as deposit for the following) Select Payment Method Corporate Account Cash Check Visa Master Card American Express Discover Credit Card Number: Credit Card Expiration Date: --mm--JanFebMarAprMayJunJulAugSepOctNovDec--yyyy--2005200620072008200920102011 Credit Card Security Code: Prior Authorization is required for all HMO, Insurance or Public Assistance ADDITIONAL INFORMATION Notes:

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