Paratransit Tour Service in Costa Rica Vaya con Silla de Ruedas, S.A. "Go with Wheelchairs" Tel/Fax: (506) 454-2810 / Cell (506) 391-5045 email: vayacon@racsa.co.cr www.gowithwheelchairs.com

Vaya con Silla de Ruedas Questionnaire Dear Client: Thank you so much for choosing Vaya con Silla de Ruedas "Go with Wheelchairs". Our staff is at your service to make your trip as safe and comfortable as possible. We would appreciate your evaluation of our company. Please take a few moments to complete this questionnaire and send it back as soon possible. Vehicle Superior Excellent Good Fair Poor Appearance           Performance           Comfort           Elevator           Other Safety Equipment           Overall Performance             Driver Superior Excellent Good Fair Poor Appearance           Ability to drive vehicle           Ability to operate equipment & secure passenger(s)           Courtesy           Knowledge of the route           Sensitivity to passenger’s needs             Guide Superior Excellent Good Fair Poor Appearance           Ability to conduct tour           General or specific knowledge of Costa Rica           Courtesy           Sensitivity to passenger’s needs             Tour Superior Excellent Good Fair Poor Tour/transfer value for the price paid           Please rate our service on an overall basis           How does our service compare with others which you might have taken?           How did you hear about our company?     Additional comments and/or suggestions regarding your trip with us:         May we use you as a reference and/or any photographs taken on your trip for future publications or web site use?      Yes___    No___     _________________________   _________________________ Print Name Signature ____________________________________________________ Address ____________________________________________________ City/State/Country _________________________   _________________________ Telephone Fax _________________________   _________________________ Date Email Muchas gracias/Thank you very much. Important Facts and Company Policies Client Information Form Vaya en Silla de Ruedas, S.A.: General Release of Liability Questionnaire