Form Login Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form. When setting up accounts for the form, we ask for an email address. This email address will only be used to provide you with login details and for recovering lost username/password combinations. NO SPAM!

SafeRide Service Reservation Request

Fill in the information below to request a reservation for a team of SafeRide America drivers to drive you and your car home for you. Please give us as much detail as possible.

We will either call or email you a confirmation.

If after submiting this reservation you would like to make changes to any detail please call us at 404-888-0887.

Although you must use a credit card to hold this reservation you can pay with the card or in cash without having anything billed to your card.

Name & Contact Information

* First Name

* Last Name

* Email Address

* Phone

* Are you a member?

Yes

No

Pick-up Details

* Are we picking you up from a business or a residence?

Business

Residence

What is the name of the business, sub-division or apartment complex?

Pick-up Street Address

Address Line 2

City

State

Zip Code

Pick-up Location Phone Number (Optional)

* Number of people in your party

Reservation Type

* Select type of reservation. (Select one)

FIRM Reservation (For a set specific time)

FLEX Reservation (This is for when you are not exactly sure when you want to be picked up. This option allows for a two hour window of time and you must call at least one hour before you want to be picked up.)

Enter FIRM Reservation Details Here

SafeRide Service Pick-up Date

If the pick-up time is not listed below, that means we are booked for that time.

Firm Pick-up Time

Enter FLEX Reservation Details Here

SafeRide Service Pick-up Date

Earliest Pick-up Time

Latest Pick-up Time

To insure a prompt pick-up time, I acknowledge and understand that I must call 404-888-0887 at least one-hour before I want to be picked up.

Pick-up Details

* What kind of car will we be driving? Enter the make and model.

* What color is the car?

* Type of transmission

Automatic

Manual (Stick shift)

Special Instructions

Drop-off Details

Street Address

Address Line 2

* City

State

Zip Code

SafeRide Driver Request

* If you prefer to have a particular driver, enter their name here, if not enter none.

SafeRide Service Rates

The basic rate for SafeRide Service is
$20 pick-up fee plus $2.50 per mile, plus tip to the drivers

If picked up from a sponsoring location or a members home
$15 pick-up fee plus $2.50 per mile, plus tip to the drivers
CLICK HERE to see a list of sponsoring locations

If you are a Project 21 Member
$10 pick-up fee plus $2.50 per mile, plus tip to the drivers
CLICK HERE to learn how to become a Project 21 Member

* Choose the rate that applies to you (Rate chosen will be verified and adjusted if necessary)

$20 pick-up fee, plus $2.50 per mile, plus tip to the drivers (Non-Member/Non-Sponsoring Location)

$15 pick-up fee, plus $2.50 per mile, plus tip to the drivers(Member/Non-Sponsoring Location or Non-Member/Sponsoring Location))

$10 pick-up fee, plus $2.50 per mile, plus tip to the drivers (Member/Sponsoring Location)

Unsure? Please contact us to discuss the rate.

Credit Card Information

Name on Card

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

CSC Code

Billing Zip Code

* Indicates Response Required

Black	White	Gray/Silver
Light Blue	Dark Blue	Red/Burgundy
Green	Yellow/Gold	Orange
Brown/Beige	Purple	Other