REQUEST OF BUDGET

NAME/COMPANY NAME:

CONTACT PERSON: ID CARD/COMPANY TAX CODE :


TELEPHONE: FAX: EMAIL:

DEPARTURE PLACE :

DEPARTURE DATE : DEPARTURE TIME:

DESTINATION:

ADDITIONAL DISPLACEMENTS : (dates, eschedules, places.. as exactly as possible)

RETURN DATE: RETURN TIME:

NUMBER OF WHEELCHAIR ANCHORED TO THE FLOOR :

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