Mg-A Order Form Update- 119
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- Myron Hutchinson
- 5 years ago
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1 This form is designed to be filled out using Adobe Acrobat. Date: PO #: Mark For: Ordered By: Address: 5720 Arville St. Suite 105 Las Vegas, Nevada Ph: Fax: Mg-A Order Form Update- 119 City: State: ZIP: Phone: Fax: Lasher Sport Mg-A $6, MGA Magnesium frame, adjustable axle wheelchair Shipping Information Ship to: Address: Address: City: State: ZIP: Provence: Frame Style Shipping Phone: Shipping Notes: Country: Seat Width Measurement from outside of seat tubes at rear of seat upholstery. 14 (35.5cm) 15 (38.1cm) 20 (50.8cm) +$495 E2201 Seat Depth Measurement from front of backrest post to front edge of seat sling. 14 (35.5cm) 15 (38.1cm) Frame Dimensions Seat Width Taper 00SWT Measurement from outside seat tubes at front of seat upholstery. No Taper 1 (2.5cm) Taper from rear seat width to front seat width +$295 00SWT-1 Rear and Front Seat Widths- 14 R x 13 F 17 R x 16 F 20 R x 19 F 15 R x 14 F 18 R x 17 F 16 R x 15 F 19 R x 18 F 2 (5.0cm) Taper from rear seat width to front seat width +$295 00SWT-2 Rear and Front Seat Widths- 14 R - N/A 17 R x 15 F 20 R x 18 F 15 R x 13 F 18 R x 16 F 16 R x 14 F 19 R x 17 F Frame Depth 00FD Depth measurement in front of seat upholstery at knee bend. Standard Length 00FD-SL Compact -1 (-2.5 cm) 00FD-C Long +1 (+2.54cm) 00FD-L 20 (50.8cm) +$495 E2203 Ergonomic Seat 00ES Measurement from front of backrest post to center of upward bend. None- No Ergonomic Seat Axle Brace Style Adjustable center of gravity axle brace. 5 Position Adjustable Axle 4 (10.2cm) +$495 00ES-4 5 (12.7cm) +$495 00ES-5 6 (15.2cm) +$495 00ES-6 7 (17.8cm) +$495 00ES-7 8 (20.3cm) +$495 00ES-8 * 5 position axle is adjustable up to 1 (2.54cm) forward and 1 (2.54cm) backwards by half inch (1.3cm) increments. Axle may have a different shape depending on the rear seat height.
2 Front Seat Height Measurement from floor to top of front seat rail (41.9cm) 17.5 (44.5cm) 18.5 (47.0cm) 19.5 (49.5cm) 20 (50.8cm) 20.5 (52.1cm) 21 (53.3cm) Front End Angle The angle from the floor to the down tube Wheel Camber Wheel Camber is set at 2 2 Frame Dimensions Continued Rear Seat Height Measurement from floor to top of rear seat rail. 15 (38.1cm) 15.5 (39.4cm) 16.5 (41.9cm) 17.5 (44.5cm) 18.5 (47.0cm) 19.5 (49.5cm) 20 (50.8cm) Rear Axle Center of Gravity ** This model has a fixed (non-adjustable) axle. Measurement from front of backrest post to center of axle. 1.0 (2.5cm) 1.5 (3.8cm) 2.0 (5.0cm) 2.5 (6.4cm) 3.0 (7.6cm) 3.5 (8.9cm) 4.0 (10.2cm) 4.5 (11.4cm) Rear Wheel Offset Measure from outside of backrest post to inside of tire. (Gap between wheel and post)..75 (1.9cm) 1.00 (2.5cm) 1.25 (3.2cm) 1.50 (3.8cm) Footrest Width Measurement from inside of footrest post to inside of opposite footrest post (25.4cm) 10.5 (26.7cm) 11.0 (27.9cm) 11.5 (29.2cm) 12.0 (30.5cm) 12.5 (31.8cm) 13.0 (33.0cm) 13.5 (34.3cm) 14.0 (35.6cm) Footrest Height Measurement from floor to top of front of footrest. (adjustable) 2.0 (5.0cm) 2.5 (6.4cm) 3.0 (7.6cm) 3.5 (8.9cm) 4.0 (10.2cm) 4.5 (11.4cm) 5.0 (12.7cm) 5.5 (14.0cm) 6.0 (15.2cm)
3 Back Height Measurement from rear seat base to top of back (30.5cm) 12.5 (31.8cm) 13.0 (33.0cm) 13.5 (34.3cm) 14.0 (35.6cm) 14.5 (36.8cm) 15.0 (38.1cm) 15.5 (39.4cm) 16.0 (40.6cm) Other Footrest Style 01FS Frame Dimensions Continued Back Angle The angle from the floor to the back rest tube vertical 93-3 recline 96-6 recline 99-9 recline Other- Chair Options and Accessories Open Loop Tube Open Loop Double Tube- +$125 Aluminum Plate- +$225 Angle Adjustable Aluminum- $295 01FS01 01FS02 01FS03 * Black Only 01FS04 Plastic Plate- +$195 Carbon Plate- +$395 01FS05 01FS06 01FS07 Carbon with Adjustable Width Flared Sides- +$595 Footrest Finish 02FF Satin Finish Mirror Polished- +$145 02FF01 02FF02 Powder Coat Frame Color- +$165 Anodize Black- +$195 Custom Color Anodized- +$295 02FF03 02FF04 02FF05 Front Caster Forks 03CF Unitine, Aluminum Silver Black Powder Coat Frame Color- +$150 Custom Color Anodized- +$295 03CF01 03CF02 03CF03 03CF04 Frog Legs Phase One (Ultra Sport), Aluminum- +$350 E1015R, E1015L Silver Black 03CF05 03CF06 Frog Legs Phase 2 Hybrid, Aluminum/Carbon- +$495 E1015R, E1015L Black Unitine Fork Phase One Fork 03CF06 (Shock Absorbing) Front Casters 04FC Phase 2 Fork (Shock Absorbing) Epic Wide, Soft Roll, Aluminum Hub 04FC01 Select Caster Size 3 x1.4 04FC x1.4 04FC x1.4 04FC01-5 Select Hub Color Silver S Black B Custom Anodize- - +$225 CA Frame Color- - +$175 FC Epic Narrow, Firm Roll, Aluminum Hub 04FC02 Select Caster Size 3 x1 04FC x1 04FC x1 04FC02-5 Select Hub Color Silver S Black B Custom Anodize- - +$225 CA Frame Color- - +$175 FC
4 Rear Wheels 05RW Chair Options and Accessories- continued Rear wheel size * Rear wheel size is required even if no wheel option is chosen. Chair will be built to the wheel size selected. 24 (540) 25 (559) 26 (590) Rear wheel model Omit rear wheels- BYOW (Bring your own wheels) List wheel model, size, and tire you will be using with your chair- Hand Rims 05RW-OMIT Sun Zero G Wheel, black spokes, black hub- No Charge 05RW-SZG Spinergy Wire Wheel, silver spokes, black hub, 30 spokes- +$320 05RW-SWW Spinergy Spox, black spokes, silver hub, 18 spokes- +$695 05RW-SS For the wheel models below, please make spoke color choice below right Spinergy LXL, black hub, 18 spokes- +$795 05RW-LXL Spinergy Blade LXL, black hub, 18 spokes- +$895 05RW-LXLB Spinergy LX, 12 spokes- +$895 05RW-LXS Spinergy XLX, 12 spokes- +$950 05RW-XLXS Spinergy LX FlexRim, 12 spokes- +$1270 * Includes integrated FlexRim pushrim 05RW-LXFS Spinergy XLX FlexRim, 12 spokes- +$1320 * Includes integrated FlexRim pushrim 05RW-XLXFS Spinergy SLX, 24 spokes- +$895 05RW-SLXS Spinergy XSLX, 12 spokes- +$950 05RW-XSLXS 06HR 05RW-LXB 05RW-XLXB 05RW-LXFB 05RW-XLXFB 05RW-SLXB 05RW-XSLXB Spoke Color Choice Black spokes Blue Spokes Red Spokes Yellow Spokes Orange Spokes Green Spokes Pink Spokes Purple Spokes White Spokes Sun Zero G Spinergy Wire Spinergy Spox Spinergy LXL Spinergy Blade LXL Spinergy LX Spinergy XLX Spinergy LX FlexRim Spinergy XLX FlexRim Spinergy SLX Spinergy XSLX Hard Anodized- No Charge Natural Fit Q-Grip- Option- +$295 Natural Fit- +$375 Natural Fit LT- +$375 Choose Finish- * Rubber Coated hand rim 06HR-NFO 06HR-NFLT 06HR-NFQ Choose Thumb Ring- Choose Thumb Ring- Clear Anodized (Silver) 06HR-HAC No Thumb Ring No Thumb Ring Black Anodized- +$195 06HR-NFNT 06HR-NFNT 06HR-HAB Standard Thumb Ring- +$145 Standard Thumb Ring- +$145 Color Anodized- +$395 06HR-NFST 06HR-NFST Color Choice- Super Grip Thumb Ring- +$175 Super Grip Thumb Ring- +$175 06HR-HCA 06HR-NFSG 06HR-NFSG Other- List Make and Model- +$TBD 06HR-OHR Tires 07T Primo- 1 (25mm) wide 07T-P * Primo tire not pictured. Schwalbe Marathon- 1 (25mm) wide- +$129 07T-SMP Schwalbe One- 1 (25mm) wide, 24 or 25" only- +$129 07T-SO Schwalbe Right Run- 1 (25mm) wide- +$99 07T-SRR Schwalbe Airborne- 1.2 (30mm) wide, 24 or 25" only- +$159 Marathon One Right Run Airborne 07T-SA
5 Wheel Locks 08WL Chair Options and Accessories- continued Omit Wheel Locks Compact Composite Scissor Locks- +$295 Push Locks- +$295 08WL-O 08WL-CS 08WL-PL Side Guards 09SG * Aluminum Side guards will be finished with the same finish and color as the main frame. None Aluminum- +$395 09SG-NO Mounting Style- Backrest Style 10BS Bolted 09SG-AB Removable- +$125 09SG-AR Carbon- +$595 Carbon w/ fender, bolted- +$695 Mounting Style- Mounting Style- Bolted 09SG-CB Removable- +$125 09SG-CR Bolted 09SG-FB Removable- +$125 09SG-FR Folding, non-locking Folding, locking- +$225 10BS-FNO 10BS-FL 10BS-W Backbar Style 11BB Classic Back Bar Rounded Sport Back Bar- +$225 11BB-CB 11BB-RB Fixed (welded), non-folding- +$295 Back Upholstery 12BU Fabric Back (choose one) Tension Cord Padding Style (choose one)- Original- Nylon cloth over foam 12BU-TON Sport- Spacer Fabric over Neoprene +$225 12BU-TSF * Includes Rear Velcro Pocket Velcro Adjustable Strap- $295 Padding Style (choose one)- Original- Nylon cloth over foam 12BU-VON Sport- Spacer Fabric over Neoprene +$225 12BU-VSF * Includes Rear Velcro Pocket Seat Upholstery 13SU Rigid Back ADI Carbon Height (choose one)- 10 (25.4cm) Low +$795 12BU-C10 13 (33cm) Mid +$895 12BU-C13 High +$995 12BU-C16 Contour (choose one)- Active 2.5 (6.3cm) -A Deep -A 4 (10.2cm)- +$125 -D Mounting Brackets (choose one)- Fixed Elite- Stationary mount, fixed positioning -FE 2 Point Pro- Stationary mount, adjustable positioning- +$95-2P Optional Accessory- Privacy Flap- +$95 12BU-PF Tension Cord Rigid Carbon Plate- +$695 13SU-TC Seat Cushion 14SC None Basic Foam- $165 Other Cushion- Make/Model- - $TBD Frame Caps 15FC Push Handles 16PH None Aluminum- Removable- +$295 Carbon- Removable- +$395 Fold Down Composite- +$495 16PH-N 16PH-AR * Requires locking back. 16PH-CR * Requires locking back. 16PH-FD Accessories 17A * Rounded caster caps are standard. Arm Rests, Swing Away- +$595 Anti-Tipper, Removable- +$595 Neoprene Frame Bumpers- +$125 13SU-RC 14SC-N 14SC-BF 14SC-OC Satin Nylon Calf Strap- 2 (5cm) wide- +$105 Black Anodized- +$195 15FC-S 15FC-P 15FC-B 15FC-C 17A-AR 17A-AT 17A-FB 17A-CS Polish- +$95 Custom Color- +$395 * Requires locking back.
6 Frame Finish- Color Options Powder Coat- Standard Finish- Included * Powder coat is a baked on finish. * Colors and shades can look different than the samples below. Powder Coat- Premium Finish- +$495 * Powder coat is a baked on finish. * Colors and shades can look different than the samples below. Gloss White PSS-5690 Sunshine Yellow PSS-2600 Rose Gold PMB Ultra Illusion Green PMB-5346 Heritage Cream HSS-1846 Honda Yellow PMB-1657 Illusion True Copper PMB Illusion Tropical PMB-6919 Satin Titanium UMB-1860 Neon Yellow PSS-1104 Light Shattered Glass PPB-6659 Pastel Blue PPB-4559 Heavy Silver PMS-517 Energy Green PSB-6669 Illusion Malbec PMB-6906 Illusion Pacific PMB-6911 Galaxy Silver PMB-4936 Racer Green PSS-4531 Oxblood Ransom PPB-4537 Aurora Blue PPB-6006 Mega Grey PMB-6831 Tractor Green PSS-4517 Illusion Rootbeer PMB-6924 Illusion Blueberry PMB-6908 Gloss Black USS-2603 Signal Green PSS-2786 Illusion Copper Plus PMB-5043 Illusion Royal PMS-6925 Royal Maroon PSB-5076 Army Green PSB-4944 Illusion Red PMS-4515 Lollypop Blue UPS-2502 Vampire Red PSS-3013 Tropical Breeze PSS-6837 Lollypop Red UPS-1506 Dazzling Blue PPB-4329 Really Red PSS-4416 Miami Teal PSB-6532 Illusion Cherry PMB-6905 Bentley Blue PPB-4711 Astatic Red PSS-1738 Bic Blue PSB-6932 Illusion Orange PMS-4620 Chameleon Sapphire PPB-5729 Sweet Raspberry PSB-6896 Deere Blue PSB-4785 Illusion Shocker PMB Lollypop Purple PPS-1505 M&M Orange PSS-5678 Ford Dark Blue PSB-4624 Flat Shocker Yellow PPB-6524 Illusion Purple PSB-4629 Harley Orange PMB-2829 Sinbad Purple PSS-1676 Illusion Sour Apple PMB-6913 Illusion Violet PSS-4514 International Orange PSS-2779 Sweet Plum PSS-1054 Psycho Green PPB-4658 Illusion Pink PMB Caterpillar Yellow PSS-2550 Whimsy Pink PSS-0874 Illusion Green Ice PMB-7025 Racing Raspberry UPB-6610 Hot Yellow PSS-1623 Lazer Polka Pink PMB-2340 Illusion Money PMB-6917 Corkey Pink PPS-5875
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q q q q q q q q q q q q q q q q q q Frame q Titanium Frame K5-CAT5-TITAN $ Includes hangers and base frame. Does not include Cross Braces.
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 APEX ORDER FORM - International P.O. number:*
4.6. Clinician/ATP/RTS: City: State: C2MA029 * Required
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 P.O. number:* Date: Ship to:* Helio C2 ORDER FORM - USA Company Name:*
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2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 APEX ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
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Account Number: Provider Name: Contact:
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2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 VELOCE ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
Parts Catalog Issued: Apr 11, A-4 A-4 Titanium. (Wheelchairs Built After 9/15/02)
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SEATING CHOICE TITANIUM FRONT FRAME
Manual Wheelchair Retail Prescription Form Champion140618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Account No : Contact
Order Form. English Company stamp. Version mudguard (AVAILABLE ONLY WITH REAR WHEELS 24'') Version straight sideguard
NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 33 36 39 42 45 48 The seat width is measured from the outer sides of the frame, while the distance
noir 2.0 Order Form NONO Carbon fibre frame made-to-measure. English Company stamp Date User name Responsible Seat depth (PS)
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FUZE T20. Order Form - Canada Prices in Canadian Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
STELLAR GL. Order Form - USA Prices in U.S. Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
Please make your selection with a cross in the box Standard feature Free of Charge
Manual Wheelchair Retail Prescription Form Champion161116 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk JANUARY 2017 Account No : Built in
STELLAR. Order Form - USA Prices in U.S. Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
FUZE T50. Order Form - USA Prices in U.S. Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD
P.O. number:* Company Name:* Ordered by:* 2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com Date: Phone:* 4.7 Ship to:*
Quickie 2 January 2014
Mark For: Submitting for: Quote Order Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: ZIP: Dealer Phone: ( ) Fax: ( ) Address: Confirmation Email: Ship To City: ST: ZIP: Confirm
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: City: Province:
519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 orders@motioncomposites.com www.motioncomposites.com 4.2 Helio C2 ORDER FORM - CANADA
Quickie IRIS January 2014
Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: ZIP: Address: Dealer Phone: ( ) Fax: ( )
RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"
Manual Wheelchair Retail Prescription Form ACTION515112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref: Contact
SEAT BACKREST. REAR SEAT HEIGHT SELECTION: independant of rear wheel size. Rear seat height in cm (2)
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Order Date : carbon. Tension adjustable seat, option DDA0611 is not possible with seat width 320mm
Manual Wheelchair Retail Prescription Form KSeriesCarbon061218 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk January 2019 Customer Ref:
FUZE T20. Order Form - USA Prices in U.S. Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Tag v.070118 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a
VELOCE 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Caster sizes Height available +- 1/4" 3" Caster 14" to 21" Specify desired height:
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 VELOCE ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
Address: City: State: Zip: City: State: Zip: TiLite Information. Please Fax to the TiLite Customer Service Team at or
Page 1 of 7 DEALER INFORMATION RTS INFORMATION Dealer: RTS: Phone: Account: PO: Email: Ordered By: SHIP TO INFORMATION Address: Name: Ship Via: City: State: Zip: Address: Phone: Fax: City: State: Zip:
SPEEDY 4all "Classicline"
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH SPEEDY
Quickie 2 EIQ2N Effective April 2011
Quickie 2 EIQ2N Effective April 2011 ACCOUNT #: SHIP TO: DATE: NAME: P.O. #: ADDRESS: BUYER: CITY/ STATE: MARKED FOR: ZIP CODE: PHONE NUMBER: The HCPCS codes provided are based on code verification by
q Little Wave Flip XP-Rigid Base E1233, E1161 $
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Order Form. English Company stamp
NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 24 27 30 33 36 Seat depth (PS) 27,5 30 32,5 35 37,5 40 Seat depth can be increased by 2,5 or 5 cm.
Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN
Invoice address: same as company address. Invoice address: other (see below) Cust. no.: Name: Street: Postcode, city: Phone: Fax: Contact:
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH TRAVELER
BEARINGS BEARINGS
TIRES PNEUMATIC.... 1-4 SNAP ON.....4 PRIMO HIGH PERFORMANCE......5-6 SCHWALBE HIGH PERFORMANCE.....5-6 KENDA HIGH PERFORMANCE... 7 MAINTENANCE FREE TIRES SHOX URETHANE TIRES..... 8 URETHANE TIRES....
Parts Catalog Issued: Apr 11, Crossfire T6A. Wheelchair
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Parts Catalog Issued: Apr 11, Crossfire T7A. Adjustable Rigid Wheelchair
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October 2018 EIQ2X. Mark For: Submitting for: Quote Order. ADDITIONAL SHIPPING INFORMATION Dealer Contact: Price. Option # 1. FRAME 002RS1 002RS2
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Küschall K Series DEALER Maximum user weight 120kg ( 19 Stone )
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed LPF1U2KSERIES021213D CF35 5AQ LPF0019X Tel: 01656 776222 Fax: 01656 776220 January 2014 email: ordersuk@invacare.com
YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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4.8. A6MA085 Italian Manual. 3" caster 4" caster. 8" caster Stem bolt Length. + 2,54 cm 1" + 5,08cm 2" STD. 36,8cm 14,5" 34,3cm 13,5" 39,4cm 15,5"
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio A6 ORDER FORM - INTERNATIONAL P.O.
Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg
QUICKIE IRIS Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: E-Mail: E-Mail: Tel: Fax: Tel: Order date: Marked for: Purchase order: Number required: Sunrise order no: Base
NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.
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3 A7WC10 E-Motion adaptor Kit (2 adaptors)
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 Helio A7 ORDER FORM - INTERNATIONAL P.O.
BUDDY "Classicline" Active easy running wheelchair
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH BUDDY
4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:
519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 www.motioncomposites.com Account: Vendor: Date: Ordered by: Email: Marked for: User
Frame Width. Seating Setup. q 16 q 15 q 14 q 17 q 16 q 15 q 14 Short q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14
Phone 0800 5 Fax 0800 5 365 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Focus CR $ 36kg weight capacity. Tilt range: -5º anterior to 50º posterior. Effective /0/0 Ship To: Address:
champion Standard Base Price 1,875 Standard Features
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION290514D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
Page 1 of 5 Purchase Order Tag Dealer/Organization Name Purchaser Name and Contact Information Mailing Address Shipping Address Please send your completed order form by email to info@pdgmobility.com or
Quickie 2 AADL - W137
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UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY.
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Phone 0800 5 222 Fax 0800 275 65 Effective /06/207 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Little Wave Flip XP - Rigid Base KF-XPRIGID $ 9.8kg weight capacity. One time free
IT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE.
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Manual Wheelchair Pencoed Technology Park. DEALER Prescription form Pencoed. CF35 5AQ. LPF1U2ULTRALIGHT211113D Tel: Fax:
Invacare Ltd Manual Wheelchair Pencoed Technology Park DEALER Prescription form Pencoed. CF35 5AQ LPF1U2ULTRALIGHT211113D Tel: 01656 776222 Fax: 01656 776220 LPF0020X email: ordersuk@invacare.com January
AADL #W643 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
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NXT Pediatric. Manual Wheelchair. Transport Optional Base
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C2 FRONT Seat-to-floor Height - Please select your choice. Custom Technologies Limited. 40 Raywood Crescent TAUPO. New Zealand
4.7 160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com Helio C2 ORDER FORM - INTERNATIONAL P.O.
Click here to download for free Adobe Reader or to purchase Adobe Acrobat.
The average annual per capita paper use in the USA in 2001 was 700 pounds. The average annual per capita paper use in the rest of the world was 110 pounds. This is equal to approximately 28 print outs
4.8. Name: K0005. Stem bolt Length /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required KDMA063 English Manual (STD) Manuel Français
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 P.O. number:* Date: Ship to:* Company Name:*
Town: Postal code: Town: Postal code: CLIENT MEASUREMENTS. Seat Width in cm 38 cm 40 cm 42 cm 44 cm 46 cm. 40 cm
Front Castor Seat Depth in cm Deliver to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required: