Ride Request Form

1

Pick-Time?

Now/ASAPSchedule a Time

2

Desired Pick-up Date/Time?* This field is required.

Date

Hour

Minutes

3

Item Prepaid or Postpaid?Has the item(s) already been paid for:

Prepaid (Item already paid with merchant)

Postpaid (Item not yet paid for)

4

Sorry we're currently not accepting post-paid items* This field is required.

Return when item is paid

5

Item's Pick-up Location:

In Albuquerque

Outside Albuquerque

6

Number of items* This field is required.NOTE: Items in 1 container can count as 1 item

7

Heaviest Item's approximate weight? (In lbs.)

lbs

8

Weight tax

9

Pick-up Address? * This field is required.

10

One Drop-off Location?

YESNO, multiple

11

Drop-off Address? * This field is required.

12

Enter Item Pick-Up and Drop-Off Addresses:

13

Base (pick-up fee)

14

Add Relevant Image/File? - (Optional)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Approx. item value?* This field is required.

Below $200

Above $200

16

Anything highly Fragile?

YESNO

17

Disclosure* This field is required.By using our delivery service, you agree: Q Ride is not liable for any lost, stolen, or damaged goods in the process of transporting your items for delivery. Q Ride simply connects customers to qualified drivers who are tasked with completing the delivery.

Accept Terms

18

Contact Name* This field is required.Person ordering

First Name

Last Name

19

Contact Number* This field is required.

Area Code

Phone Number

20

Receive Price Quote by email?Otherwise phone number will be used

YesNo

21

E-mail* This field is required.To receive an email quote

22

Receive Price Quote or pay now?Otherwise, phone number will be used

QuoteQuote and Pay

23

Any additional information? (optional):Pick-up instructions, Item description etc.

24

Your SignatureBy signing below you confirm that you are the authorized signer on this card and that you approve the Transaction amount

Clear