Rental Questionnaire - Life Improved

Who will be the responsible party for this rental? *

First Name

Last *

Last Name

Phone *

Email *

Billing Address *

City *

State *

Zip Code *

Will the responsible party above be the same as the person receiving the rental AND at the same address? *

Yes

No

Who will be receiving this rental? *

First Name

Last *

Last Name

Address *

Address

Street Address (no PO Boxes)

Address

City

State/Province

Zip/Postal

Phone

Phone Number of Person Receiving the Rental

Who Referred You To Us? *

Distributor Name (required if referred by a Bemer Distributor) *

Distributor Email (if known)

Distributor Phone (if known)

Other

please let us know how you heard about us

I am interested in: (please check all that apply)

Bemer Pro Set $199/week

B. Sit $29/week

Bemer Vet Horse Set $249/week

Duration of rental (weekly increments, 3-weeks minimum)

please click one

If other *

How would you like to receive your rental?

Pick up in Chandler, AZ

Please ship it (no charge for UPS Ground)

please click one

Zip Code to be shipped to

When would you like your rental to begin?

Comments (optional)