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Rental Application Form

Please enter the required information in the fields below and then click the “Confirm” button.

Please provide all responses in English.
Required fields are indicated by a red asterisk *.

    1. Rental

    Rental Period *
    Start Date
    End Date
    Rental Period：
    0days
    ※ If you have a preferred delivery date and time, please enter it in the request field on this application form.
    ※ Reservations can be made for dates starting from seven days after today.
    ※ Rental fees are automatically calculated based on the start date and return date.
    ※ Depending on the timing of your reservation and stock availability, we may not be able to deliver the product on your preferred date and time.
    ※ Reservations submitted on non-business days (such as weekends and public holidays) or outside business hours will be processed on the next business day.
    Select a Model *
    • （Nickel-Metal Hydride Battery）Endurance Mileage (per charge): 15km
    • （Lithium-Ion Battery）Endurance Mileage (per charge): 30km
    • （Nickel-Metal Hydride Battery）Endurance Mileage (per charge): 16km
    • （Lithium-Ion Battery）Endurance Mileage (per charge): 27km
    • Endurance Mileage (per charge): 7km
    Number of Electric Wheelchair

    1unit

    ※If you would like to rent multiple units, please fill in the model and number of units in the request field on this application form (5).
    We will provide you with a separate quote.
    Choose an Option
    Peace of Mind Coverage
    （500yen / day）

    2. Receiving and Returns

    • How to Receive Your Rental Item *
      ※Please come to the store on the rental start date.
    • Store List *
    • Shipping Address *

      ※Excluding Okinawa Prefecture and remote islands.

    • How to Return Your Rental Item *
      ※Please come to the store on the last day of your rental or hand it over to the delivery company.
      ※Please come to the store on the last day of your rental.
      ※Please hand over the item to the delivery company on the last day of your rental.
    • Store List *
    • Shipping Address *

      ※Excluding Okinawa Prefecture and remote islands.

    3. Total Amount

    • Rental Fee（tax exemption）
    • Shipping Fee（tax included）
    • Peace of Mind Coverage
    • Security Deposit
      50,000yen (Refunded after return)
      -
    • Total

    4. Customer Information

    • Renter *
    • Full Name *
    • Company Name *
    • Contact Person *
    • Address Line 1 *
    • Address Line 2
    • City *
    • State/Province/Region *
    • Country *
    • Postal Code *
    • Phone Number *
    • E-mail *
    • E-mail (confirmation) *
    • Relationship with Users *
    • User Name *

      ※The electric wheelchair user's name should be entered.

    • User's Date of Birth
    • Gender Section *
    • User Address *
    • Address Line 1 *
    • Address Line 2
    • City *
    • State/Province/Region *
    • Country *
    • Postal Code *
    • Delivery Address *
    • Address Line 1 *
    • Address Line 2
    • City *
    • State/Province/Region *
    • Postal Code *
    • Return Shipping Address *
    • Address Line 1 *
    • Address Line 2
    • City *
    • State/Province/Region *
    • Postal Code *
    • Return Shipping Address *
    • Address Line 1 *
    • Address Line 2
    • City *
    • State/Province/Region *
    • Postal Code *
    • Identification Documents*

      Regarding identity verification documents.

    • Upload
      ◎ Type of certificate: Driver's license, Individual Number (My Number) card, Basic Resident Register card, Driving history certificate, Physical disability certificate, Mental disability health and welfare certificate (Disability certificate), Rehabilitation certificate, Passport or Residence card
      ◎ File format: JPG, PNG, BMP, PDF, Compressed file (ZIP, RAR, 7Z)
      ◎ File size: 5MB or less
      ◎ If you upload multiple files, older files will be overwritten, so please upload them as a compressed file.
      ◎ The documents submitted are internal company documents and will not be disclosed to other companies.
    • Important Notes
      ◎ Type of certificate: Driver's license, Individual Number (My Number) card, Basic Resident Register card, Driving history certificate, Physical disability certificate, Mental disability health and welfare certificate (Disability certificate), Rehabilitation certificate, Passport or Residence card
      ◎ Please send within three days from today.
      ◎ Mailing address: 3-8-30 Nagata, Higashiosaka City, Osaka Prefecture 577-0015
      ◎ Fax number: 06-7664-8812
      ◎ The documents submitted are internal company documents and will not be disclosed to other companies.

    5. Questions Or Requests

    6. Terms and Conditions *

    Please see the Terms and Conditions（PDF）

    Contact

    Genki Kobo

    3-8-30 Nagata, Higashiosaka City, Osaka Prefecture 577-0015
    Phone Number：0120-41-2943
    FAX：06-7664-8812
    E-mail：rental@genki-kobo.com

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