OFFICE INFORMATIONAL WORKSHEET

(All Information on this form is considered confidential and not be shared)

I. PERSONAL INFORMATION:

-PAK or Monthly

Name: Date of Birth:
Gender: Male Female

Address: Phone 1: Phone 2:

Address: E-Mail:

City: State: Zip: Country:

**Person# 2: Date of Birth: Gender: Male Female

Form of Pmt:


II. TRAVEL INFO:

1 - The longest trip this person would travel to: (store, doctor, outing, etc)?

2 - The shortest trip this person would travel to: (store, doctor, outing, etc)?

3 - How many times approximately per:
Week Month Other

4 - Is an escort needed?
Yes: No:
Sometimes:

(other then no, explain)

5 - Is a companion needed? Yes: No:

Explain WHY:


III. WE HAVE 5 TYPES OF PLAN.

Type 1 Plan - Cash (pay as you go)
Type 2 Plan – Credit Card on File (we charge every time you use our service)
Type 3 Plan – 10-PAK (purchase 10 one way trips at a small discount per trip price)
Type 4 Plan – 20-PAK (purchase 20 one way trips for a much larger discount per trip)
Type 5 Plan – Monthly (pay monthly for bigger discount per trip and much, much more)

◻ Any additional information could help us with our proposal to you

Date of Call:
Time:
Approx. Date & Time to return call:

All requests will be returned no later than 2 day after receive of call.
Mail to:OHE Services, LLC 1056 Puu Alani Way, Pearl City, Hawaii 96782-2761