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Please
tick
the box to confirm that you are of 24 years or over plus that you have been driving for a minimum of 24 months.
Name in Full
*
Telephone No.
*
Email
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Address
Date of Birth
Age
24
25
26
27
28
29
30
31
32
33
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75
Driving license number
Any Disabilities
Yes
No
*
If "Yes" please state below
Are you a Student
Yes
No
Driving over 24 months
Yes
No
Catagory of Vehicle
CAR
MPV
VAN
Type of Vehicle Prefered
A-PUNTO 3D/R OR SIMILAR
B-PUNTO 5D/R OR SIMILAR
C-VW GOLF / OR SIMILAR
D-VW PASSAT / OR SIMILAR
E-VOLVO ESTATE / OR SIMILAR
Hire Period:
Start Date
Finish Date
*
Pick up time
Select
08:00
08:30
09:00
09:30
10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
17:30
18:00
Drop off time
Select
08:00
08:30
09:00
09:30
10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
17:30
18:00
*
Pick up location
Select
Burton
Lichfield
Drop off location
Select
Burton
Lichfield
*
Hire Period-Time:
Branch:
Had any endorsements within the last 10 years ?
Yes
No
Ever been banned from driving ?
Yes
No
Had any fault accident within the last 3 years ?
Yes
No
(
*
denotes mandatory fields)
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Tamworth Branch
01543 417755
Burton Branch
01283 539 123
Lichfield Branch
01543 417755
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