FUZE T50. Order Form USA. Please send your completed order form by to or by fax to

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1 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 to or by fax to O r d e r N o t e s F r a m e T y p e Fuze T50 50 Manual Tilt Wheelchair E1161 $ 2,995 F r a m e O p t I o n s Fixed Base and Seat Frame 350 lbs Weight Capacity. Select Fixed Seat Width below Adjustable Base and Seat Frame $ lbs Weight Capacity. Select Adjustable Seat Width below Frame for Plug In Front Rigging $ S e a t W I d t h Transit Tie Down System (TTDS) TTDS includes 4 factory installed-transport brackets. TTDS has been tested according to ANSI/RENSA WC 19. See Owners Manual for complete details. Fixed Seat Widths Order with Fixed Base and Seat Frame. 13" Seat Width 14" Seat Width 15" Seat Width 16" Seat Width 17" Seat Width 18" Seat Width 19" Seat Width " Seat Width E2201 $ " Seat Width E2201 $ " Seat Width E2201 $ 325 PDG Product Design Group Inc. 318 East Kent Avenue South Vancouver BC V5X 4N6 Canada Phone Adjustable Seat Widths Order with Adjustable Base and Seat Frame "-15" Range - Set at 13" "-15" Range - Set at 14" "-15" Range - Set at 15" "-20" Range - Set at 15" "-20" Range - Set at 16" "-20" Range - Set at 17" "-20" Range - Set at 18" "-20" Range - Set at 19" "-20" Range - Set at 20" E2201 $ "-22" Range - Set at 21" E2201 $ "-22" Range - Set at 22" E2201 $ 325 S e a t D e p t h Standard Seat Depths (Adjustable) 15" Seat Depth 16" Seat Depth 17" Seat Depth 18" Seat Depth 19" Seat Depth " Seat Depth E2203 $ 475 Custom Seat Depths Requires 25 Push bar Back Straight, Angle/Height Adjustable Push Bar Handle. Not compatible with Reclining or Fold Down Back " Seat Depth E2203 $ " Seat Depth E2204 $ 750 F r a m e C o l o r PDG Primary Colors Tracer Red Gloss Black Silver Black Shimmer Orange Fusion Karl s Imagination Blue Shimmer Gloss White Dark Titanium PDG Premium Colors $ 150 Geyser Green Lollipop Blue Lollipop Red Custom Color $ 300 Contact PDG for specifications.

2 Page 2 of 5 A r m T y p e No Armrest Single Post Fixed Height (12") Single Post Adjustable Height (10"-14") E0973 $ Dual Post Fixed Height (12") "-14" "-16" Set at 10" Set at 11" Set at 12" Set at 13" Set at 14" A r m r e s t s S e a t P a n Dual Post Adjustable Height E0973 $ 255 Locking Flip-up E0973 $ 255 Not recommended for clients with excessive strength or tone. Not compatible with Fold Down Back, Clothing Guards, Back Upholstery. Curved Armpads (pair) Not compatible with Lap Tray, Locking Flip-up Armrests, Dual Post Armrests. Regular Armpads Desk Length - 2" x 10" (pair) Full Length - 2" x 14" (pair) Wide Armpads $ 115 May interfere with wheels in some tilt configurations. Desk Length - 3" x 10" (pair) Full Length - 3" x 12" (pair) Gel Armpads $ 115 May interfere with wheels in some tilt configurations. Full Length - 2" x 12" (pair) Full Length - 3.5" x 12" (pair) Contour Arm Trough E2209 $ 125 Not compatible with Lap Tray, Locking Flip-up Armrests or Dual Post Armrests. May interfere with wheels in some tilt configurations. Right (4.5" x 18") with Hand Pad Left (4.5" x 18") with Hand Pad No Seat Pan Solid Seat Pan E2231 $ 120 C u s h I o n No Cushion nxt BioFit "-20" width, 16"-20" depth E2607 $ "-24" width, 16"-20" depth E2608 $ 600 Matrx VI "-20" width, 16"-22" depth E2607 $ " width, 18"-22" depth E2608 $ HD - 18"-30" width, 18"-22" depth E2608 $ 1,150 ROHO Quadtro Select HP Scan this code or visit to learn more about the Fuze T50 Manual Tilt Wheelchair "-20" width, 16"-22" depth E2624 $ "-24" width, 16"-22" depth E2625 $ 750 ROHO High Profile "-20" width, 16"-22" depth E2622 $ "-24" width, 16"-22" depth E2623 $ 750 Varilite Reflex "-20" width, 16"-20" depth E2603 $ 375 Cushion Size Specify Size (Width" x Depth") S e a t H e I g h t Circle desired Seat-to-Floor Height or enter information below: Standard T50 Options Wide T50 Options STF Height is approximate and can vary by as much as 1" depending on rear wheel type and pre-tilt setting (Standard T50 Chairs are shipped in 3 pre-tilt). To resolve, STF Height can be adjusted down by removing the pre-tlit collar/bumper. 5" Casters 12" 13" 16" 13" 14" 15" 20" 13" 14" 15" 16" 17" 5" Casters 22" 14" 15" 16" 17" 12" 13" 14" 24" 15" 16" 17" 16" 14" 15" 16" 20" 16" 17" 6" Casters & 6" Forks 22" 17" 16" 14" 15" 20" 14" 15" 16" 17" 6" Casters & 6" Forks 22" 14" 15" 16" 17" 18" 12" 14" 18" 24" 15" 16" 17" 18" 16" 14" 15" 16" 20" 16" 17" 18" 6" Casters & 8" Forks 22" 17" 18" 16" 15" 24" 18" 20" 15" 16" 17" 22" 15" 16" 17" 18" 6" Casters & 8" Forks 24" 15" 16" 17" 18" 19" 12" 18" 19" 16" 15" 16" 8" Casters & 8" Forks 20" 16" 17" 18" 20" 16" 17" 22" 17" 18" 19" 22" 16" 17" 18" 24" 18" 19" 24" 16" 17" 18" 19" 12" 8" Casters & 8" Forks 18" 19" 20" 16" 16" 20" 20" 16" 17" 18" 22" 17" 18" 19" 24" 18" 19" 20" 16" Ultra Sport Forks 16" 20" 16" 17" 18" 22" 17" 18" 19" 24" 18" 19" 20" Increases the overall width of the Chair by 2". Wheel size Caster size STF

3 Page 3 of 5 C a s t e r s Urethane 5" x 1.25" Caster size 6" x 1.25" Caster size " x 1.50" Caster size $ " x 1.25" Caster size " x 2.00" Caster size $ 135 Pneumatic " x 1.25" Caster size $ " x 1.25" Caster size $ " x 2.00" Caster size $ " Soft Roll $ Ultra Sport Fork E1015 $ 395 R e a r W h e e l s Not compatible with 12 Rear Wheels. Requires 6 Soft Roll Caster. Composite 12" Wheel size 16" Wheel size 20" Wheel size 22" Wheel size 24" Wheel size Spoke $ 75 20" Wheel size 22" Wheel size 24" Wheel size " Heavy Duty Spoke $ 350 A x l e T y p e R e a r T I r e s Quick Release Rear Axles Fixed Rear Axles Urethane Pneumatic $ 60 Pneumatic Tires may result in a finished Seat Height 1/2" greater than stated Pneumatic with Flat-Free Inserts E2213 $ 95 H a n d R I m s Pneumatic tires may result in a finished Seat Height 1/2 greater than stated. Not compatible with Spoked Wheels. No Hand Rims Standard 20", 22", and 24" Rear Wheels only Plastic Coated 20", 22", and 24" Rear Wheels only. $ 95 W h e e l L o c k s Foot Operated Wheel Lock $ Not compatible with One Arm Drive Push to Lock Pull to Lock Attendant Wheel Lock (Push to Lock) $ 85 Not compatible with Wheel Lock Extensions User & Attendant Wheel Lock $ Wheel Lock Extensions E0961 $ 60 A n t I - T I p p e r s Not compatible with Attendant Wheel Lock Rear Anti-Tippers E0971 $ Required Safety Option. B a c k P o s t S t y l e Push Bar Back Straight Bend $ Cane Handle Back Not compatible with Headrest Mounting Plate. Straight Bend $ Back Post Height Seat Pan to Handle 20" Height 25" Height B a c k O p t I o n s Angle/Height Adjustable Push Bar Handle $ 150 Not compatible with Headrest Mounting Plate or Cane Handle Back. Button on Outside Button on Inside Removable Cane Handle Push Bar $ 140 Not compatible with Push Bar Back. Seat to Back Angle Set at Set at Set at Set at Set at Set at Fold Down Back Non Fold Down Back $ 75

4 Page 4 of 5 B a c k U p h o l s t e r y No Back Upholstery Set at 18" Set at 19" Set at 20" Set at 21" Set at 22" Set at 23" Set at 21" Set at 22" Set at 23" B a c k r e s t Standard $ 125 Back height measured from Seat Pan to top of Upholstery. Not available with Cane Handle Back. Adjustable Tension $ 250 Back height measured from Seat Pan to top of Upholstery. Not available with Cane Handle Back. No Backrest nxt Optima HA AC - 16"-20" width, 16"-20" height E2620 $ PC - 16"-20" width, 16"-20" height E2620 $ AC - 22"-24" width, 16"-20" height E2621 $ PC - 22"-24" width, 16"-20" height E2621 $ 720 Matrx Elite "-20" width, 10"-20" height E2620 $ HD - 22"-26" width, 16"-20" height E2621 $ 1, Deep - 14"-20" width, 12"-20" height E2620 $ 950 ROHO Agility Min - 14"-20" width, 10"-18" height E2620 $ Mid - 14"-20" width, 10"-18" height E2620 $ Max - 14"-20" width, 10"-18" height E2620 $ 950 Varilite Icon Tall - 14"-20" width, 14"-24" height E2615 $ Deep - 14"-20" width, 17"-24" height E2620 $ 895 Backrest Size Specify Size (Width" x Height") T I l t / R e c l I n e O p t I o n s Attendant Tilt only Installed on Right Back Post Installed on Left Back Post Tilt Limit Set at Set at Set at Set at Set at Set at Set at Reclining Backrest (Manual) E1225 $ H e a d r e s t Not compatible with Headrest Extension, Cane Handle Back, Spring Back Suspension, Fold Down Back or Tension Adjustable Upholstery. Requires 25 Angle/Height Adjustable Push Bar with 8 Bend. Not available with 15, 16, 21, or 22 Seat Depth. Power Tilt E1002 $ 2,095 Tilt range 4 to 45, Max weight 250 lbs. Toggle Switch - Installed on Right side Toggle Switch - Installed on Left side Button Switch - Installed on Right side Button Switch - Installed on Left side No Headrest Headrest Mounting Plate $ 75 Not compatible with Head Rest Extension, Angle/Height Adjustable Push Bar, Cane Handle Back. Not required if mounting to a solid Back nxt MultiFit Head Support Hardware E1028 $ 155 nxt MultiFit Head Support Pad E0955 $ Regular (9" x 5") Large (10" x 5") X-Large (14" x 5") Stealth Headrest Hardware E Multi-Axis HMO475 $ Link TWB480 $ Stealth Headrest Pad E0955 $ " width 14" width F r o n t R I g g I n g No Front Rigging Sector Blocks only Plug in 70 Frame upgrade required. Select above Plug in Adjustable Knee Angle $ 975 Frame upgrade required. Select above Swing Away Swing Away 90 Not compatible with 8" Casters Swing Away Elevating Legrest E0990 $ 355 F o o t P l a t e s Composite Angle Adjustable K0040 $ One Piece Flip-up $ Interlocking Angle Adjustable K0040 $ 195 Seat Widths of 14"-21" only.

5 Page 5 of 5 F o o t r e s t / L e g r e s t A c c e s s o r I e s Swing Away 70 Calf Pad $ 135 Not compatible with 70 Gel Pad Swing Away 70 Gel Pad $ 100 Not compatible with 70 Swing Away Calf Pad Swing Away ELR Gel Knee Pad $ Adjustable Length Heel Loops E0951 $ Bodypoint - Padded Calf Strap K0038 $ 105 Miller's Dynamic Footrest Mounts For Plug In Front Rigging $ For Swing Away 70 Front Rigging $ 380 E x t e n s I o n T u b e s Not available on 13" STF Regular Extension Tubes Not compatible with Swing Away 90? Standard (13"-17") Long (15"-19") $ 75 Extra Strengh Extension Tubes (Solid) $ 100 Available on Plug In Front Rigging only Standard (13"-17") Long (15"-19") Extension Tubes (11"-16") $ 75 Not compatible with 70? or ELR. P o s I t I o n I n g S t r a p s Bodypoint - Hip Belt E Center-Pull Auto Style $ Center-Pull Auto Style, Padded $ Point, Padded $ Bodypoint - Chest Strap E0960 $ 85 M I s c e l l a n e o u s O p t I o n s One-Arm Drive E0958 $ 3,500 Requires 24 Composite Rear Wheel. Forward Wheel Position. Available with 18 and 20 STF only. Not compatible with Attendant or Foot Operated Wheel Locks. Installed on Right side Installed on Left side Stealth Flip Down Abductor E0957 $ QR Bracket - Accessory Mount $ 200 Not compatible with TTDS Gel Hip Guides $ IV Pole E1029 $ O2 Holder E2208 $ 295 May add to overall width of the Chair Ventilator Tray E1029 $ 295 Minimum Seat Width is 16. Reduces ground clearance. May become unstable when no occupant in the chair. Not compatible with O2 holder Ventilator Bracket E1029 $ 295 Compatible with LTV1 (lap tops) ventilator Ventilator Battery Tray E1029 $ 95 Minimum Seat Width is 16. Reduces ground clearance. Fits U1 Battery only. Restricted to 20, 22, and 24 Rear Wheels with seat height restrictions Clear Lap Tray (Slide On) $ 490 Not compatible with 8-11 Dual Post Arms, Desk Length Pads, or Gel Arm Pads. Seat Widths of only Adhesive Back Hook Strip, 2" x 30" $ 10 For Cushion mounting Fuze T50 to T20 Conversion Kit K0108 $ 995

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