Segs4Vets Receipt Agreement

Segs4Vets Segway Receipt Agreement

If you have not been contacted by a Segs4Vets / DRAFT Team Member asking you to complete this Receipt Agreement, please do not complete this form. To apply for the Segs4Vets program.....Click Here

Please complete all fields on the receipt agreement. Double check your responses before clicking on submit. Upon successful completion of the form, you will be re-directed to the Confirmation page of our website, and receive an email at the email address you provide on the form.

Thank you for your service.

Segs4Vets Receipt Agreement (Please fill out ALL fields)

First Name:

Last Name:

Email Address:

Telephone:

Segway Model:

Segway Serial Number:

I have completed Segs4Vets training:

I have watched the safety video:

I have received a helmet:

I will keep the Segway plugged in at all times:

I will report any maintenance issues:

Segs4Vets Trainer's Name:

Award Location:

Segway Award Date:

Select Date

Digital Signature (REQUIRED):

Click Here Once To Submit Application