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Your Name (required)

Your Email (required)

Pick up place (Fill the address, name of venue, hotel, airpot, train station, etc.)

Pick up date & time
* Please put your requested pick up time if you request pick up other than selectable time slot.

Destination (Fill the address, name of venue, hotel, airpot, train station, etc.)

Number of passengers
Wheelchair012  Accompanying0123

Wheelchair
Your own standard typeYour own electric typeYour own othersRental standard type (Free of charge while on vehicle)

Optional equipments
No thanksReclining Wheelchair

Your Message

Please confirm if all of your entries are correct especially your e-mail, and check the box left, then click "Send".

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