Hire Equipment Form

First Name *

Last Name *

Email *

Address *

Suburb *

Postcode *

Access to Property Information. Please provide any helpful information to help with the delivery of your hire equipment. (number of stairs, or rear access..etc..)

Property Access Information

Submitted Date

BILLING DETAILS

Same as Personal Details:

Yes

No

Please proceed with the next step

First Name

Last Name

PO Box Number

Address

Suburb

Postcode

HIRE EQUIPMENT DETAILS

If you know the equipment you intend to hire, please list the item or items here. Please, also include the size or style if possible.

List your Items *

HIRE PERIOD

Please note the minimum hire period is 2 weeks and charges will incur until items are returned

Do you need delivery urgently ?

Hire Start Date (if applicable / If known)

Hire Start Date

HIRE SECURITY

To secure this hire agreement you must provide Fisher Lane Mobility with a valid credit card or direct debit details and by doing so you agree to give Fisher Lane Mobility authorisation to deduct any amounts owing on this account after the due date(s) stated on each invoice.

Fisher Lane will contact you to obtain these details once this form has been submitted and received by Fisher Lane Mobility.

PAYMENT

You do not need to provide any payment details at this stage. Once you submit this form a Fisher Lane team member will contact you to discuss payment for your equipment.

I am:

I understand that the equipment hired remains the property of Fisher Lane Mobility. I also agree that Fisher Lane Mobility will accept no responsibility for any injury or damage sustained by me through the use of any equipment hired from Fisher Lane mobility. At the end of the hire period I undertake to return all equipment in good working condition and agree to pay for any damage caused while equipment is on hire other than what would be considered as normal wear and tear.

The minimum chargeable period is two weeks and billing will continue until items are returned to Fisher Lane mobility. The hire period is the time that goods are out, not time used.

ADDITIONAL INFORMATION

Please provide any information you wish to share, about you or your needs, that will help our hire consultants better assist you when we get in touch.

Additional Information

BILLING DETAILS

HIRE EQUIPMENT DETAILS

HIRE PERIOD

HIRE SECURITY

PAYMENT

ADDITIONAL INFORMATION

Order products

Order Total (The sum of all the prices of all the items in the order, taxes and discounts included.)

Contact information

Shipping address

Billing address