Personal Account Application

Passenger's Details

Financial Information
PLEASE BE ADVISED THAT A DEPOSIT EQUAL TO THE VALUE OF ONE MONTHS WORTH OF TRIPS MAY BE REQUIRED
In applying for credit with Wheelchair Taxi Online., the undersigned consents to Wheelchair Taxi Online . obtaining from, exchanging with or disclosing to a third party all information concerning the Application for the purpose of ensuring the accuracy of this information and conducting investigations. The undersigned hereby authorizes Wheelchair Taxi Online. through an affiliated company to collect Any overdue balance on my account by charging one of the above credit cards