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 * Address Date of Birth Age 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 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) Reload Image Enter captcha: Mercury Rent a Car is a family run business and has been established for over two years in the East Midlands. We are a licensee of United Rental Group, and with this makes us part of the largest independent vehicle rental networks with over 143 locations in the UK. » Read More