Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Is Your Vehicle Roadworthy? *

Yes

No

I confirm that the details provided in this application are true and correct

I have read, understood and hereby accept the terms and conditions on this page.

I authorise Car2Go to act on my behalf in recovering the replacement vehicle costs, communicating with the insurer in regards to the claim and commencing legal proceedings if the matter is in the situation where it must be defended in a court of law.