Online Application

Use this Online Application form to join the Easi-Cab Travel Club now.

Use this online application form to give us a little information so we can give you the best possible service. What mobility aids do you use if any.

Do you use a wheelchair or a walking aid. Have you got an electric scooter? Are there any other aids or requirements that you think we should know. Do you have a carer who travels with you? If so let us know.

Don't forget that we can set up a schedule for your travel needs; Trips to Day Centres, college, or work. This facility is enjoyed by lots of our Club members - they really find that it is great not having to remember to book each trip separately.

If you are not sure of anything then please contact us by phone or email. If you would like to meet us then call around at any time. We would love to meet you.

You can print the form by clicking here

Easi-Cab Travel Club Membership Form

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

Street Address*
Street Address*

City*
City*

Country*
Country*

E-mail Address*
E-mail Address*

Home Phone

Business Phone

Give us a little information so we can give you the best service. What mobility aids do you use if any.

	Wheelchair manual
	Wheelchair electric
	Electric scooter
	Wheelchair transfer
	Frame/Walking aid

What gives you the most difficulty getting out and about?

What age group are you in?

How did you learn about Easi-Cab?

	Word of mouth
	Media
	Organisations
	Web Page
	Other

Link back to Membership from Online Application OR Home page

SBI!