MOOV - Wheelchair Accessible Vehicle

Reservation powered by Allegiance Transportation

Passenger first name

Passenger last name

Passenger date of birth

Month

Day

Year

Pick-up address

Drop-off address

Date and time of appointment (if applicable)

Month

Day

Year

Time

HoursMinutes

Check here if passenger has a wheelchair

Check here if passenger is over 350 lbs

Check here to confirm passenger has a credit card on file with Allegiance

Any other special notes relevant to this trip? (optional)

Full name of person responsible for paying for this trip

Phone number of person paying for this trip

Legal Notice and Consent

By submitting this form, you certify that you are submitting a legitimate transportation request on behalf of the identified passenger. You agree that the passenger is financially responsible for all charges associated with the ride. You understand and agree that MOOV Enterprises LLC ("MOOV") is acting solely as an intake service for the purpose of forwarding your request to our authorized transportation partner, Allegiance Transportation LLC.

MOOV is not responsible for the scheduling, fulfillment, safety, or quality of the transportation services provided. MOOV disclaims all liability arising from or related to the transportation services once your request has been transferred to Allegiance Transportation. Allegiance Transportation is an independent provider and is solely responsible for the ride services rendered.

You further acknowledge that MOOV’s responsibility for your data ends upon transmitting your submitted information to Allegiance Transportation. Your information will be used only for the purpose of coordinating the requested transportation and will not be sold or used for marketing purposes by either MOOV or Allegiance Transportation. For more information about Allegiance Transportation, please visit https://www.allegiancetransportation.com/.