TiLite. Please Fax to the TiLite Customer Service Team at or
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1 - Print as guide for ordering DEALER INFORMATION ler: Adaptive Specialties RTS INFORMATION RTS: SHIP TO INFORMATION Phone: Page 1 of 9 TiLite Information Name: Ship Via: : Please Fax to the TiLite Customer Service Team at or FRAME STYLE AZFS1 TiLite Aero Z (Full Adjustability) (265 Pound Weight Limit. For Rear Seat Width and Seat Depth of 15 or greater, use K0005. For Rear Seat Width and Seat Depth of less than 15, use E1229. Weight Limit is restricted to 150 pounds on chairs with Rear Seat Width and Seat Depth from 10 x10 to 12 x12.) $2,095 K0005 TiLite Special Editions Edition options will A2P1 SuperLite Edition $175 $225 $65 (Not available with a Power Adaptable Frame. When a Power Adaptable Frame is selected, a Titanium Camber Tube will be used.). $175 A2FF2 $150 $50 Retail: $840 SuperLite Edition Price: $715 A2P4 Armed Forces Edition (Armed Forces Edition can be ordered in combination with any of the other Frame Styles. Satin or Polished Natural Titanium Finishes may also be selected with Armed Forces Edition. Neoprene Impact Guards will match Digital Camo when ordered.) $140 A2AF1 (Subdued Green painted frame with ACU digital upholstery.) A2AF2 Navy (Subdued Dark Blue painted frame with NWU digital upholstery.) A2AF3 (Subdued Green painted frame with New ABU digital upholstery.) A2AF4 (Subdued Tan painted frame with MARPAT - Desert digital upholstery.) A2AFP1 4 Logo Patch OR A2AFP2 Name Tape Patch A2AFP3 Power Adaptable Frame (No charge when 20 Rear Seat Width and 20 Seat Depth are selected. Requires Billet Aluminum Front Wheels and 0 or 2 Camber. Not available with Carbon Fiber or Titanium Camber Tubes, Titanium Quick Release Axles or Slipstream Single-Sided Forks. Camber Tube available in silver anodize only.) $300 A2RFR1 Reinforced Frame (No charge when 20 Rear Seat Width and 20 Seat Depth are selected.) $300 THE ULTIMATE RIDE.
2 WHEELCHAIR TRANSPORT BRACKETS Wheelchair Transport Bracket Option (Consists of four factory-installed wheelchair transport brackets. Unoccupied Use Only.) $315 THIS SECTION MUST BE READ The TiLite Aero Z Series 2 with Wheelchair Transport Bracket Option (A2WTB) was NOT crash-tested in accordance with ISO or ANSI/RESNA WC19. Therefore, the Wheelchair Transport Bracket Option is intended ONLY to secure an unoccupied wheelchair in a motor vehicle. The U.S. Department of Transportation has not approved any tie-down system for transportation of a user while in a wheelchair in a moving vehicle of any type. It is TiLite s position that users of wheelchairs should be transferred into appropriate seating in motor vehicles and use the restraints made available by the auto industry. Page 2 of 9 FRAME FINISHES Natural Aluminum A2FF1 Light Satin (Finished with clear powder coat.) A2FF3 Tattooed Aluminum (Tattoos on front frame tubes. Finished with clear powder coat. Click on the images below to view the Tattoos online.) $295 A2FF4 High Gloss Paint TiLite Red A2FF11 Metallic Paint A2FF14 Salsa Red Metallic A2 Pearlescent Paint Matte Paint Candy Paint A2FF22 Ruby Red A2FF23 COLOR ANODIZE PACKAGE (Color Anodize Package includes: Aluminum Camber Tube (Anodized Color not available with Power Adaptable Frame), Camber Mount, Caster Mount, Caster Fork, and Caster Caps. If no anodize color is selected, the default will be black.) $125 FRAME MEASUREMENTS REAR SEAT WIDTH (Weight Limit is restricted to 150 pounds on chairs with Rear Seat Width and Seat Depth from 10 x10 to 12 x12.) $450 E2201
3 FRAME MEASUREMENTS Page 3 of 9 FRONT SEAT WIDTH (SEAT TAPER) insideinside (2.5 Narrower than Rear Seat Width.) (4 Narrower than Rear Seat Width. Includes Tension Adjustable by Straps Seat Upholstery. Not available with 10 and 11 Seat Widths.) $250 (5 Narrower than Rear Seat Width. Includes Tension Adjustable by Straps Seat Upholstery. Not available with 10 to 14 Seat Widths.) $250 SEAT DEPTH A2SD A2SD2 $475 E2203 A2SD3 (A Custom Frame Depth of 20 is $475 if Seat Depth of 20 is not also selected.) NCO FRONT SEAT HEIGHT 21 REAR SEAT HEIGHT REAR SEAT HEIGHT RANGES Rear Wheel Size AERO Z Rear Seat Heights FRONT ANGLE A2FA1 (85 Not available with 6 Front Wheels.) (Not available with 5 or 6 Front Wheels.) $150 SEAT TO FOOTREST FOOTRESTS Measurement must be at least 2 shorter than Front Seat Height STANDARD FOOTRESTS A2FTR3 K0040 A2FTR1 $175 A2FTR2 $225 A2FTR12 (Not available w/ 10 or 11 Rear Seat Width, Heavy Duty Edition, ABS Cover w/ 2 Sides, Front Roller.) $150 HIGH MOUNT FOOTREST A2FTR4 $85 K0040 A2FTR14 ABS Cover w/2 Sides (Not available with Flip-Back Footrest or chairs with 10 or 11 Rear Seat Width.) $95 K0041
4 FRAME MEASUREMENTS FOOTREST WIDTH or Page 4 of 9 A2FE1 STANDARD FRONT END insideinside REAR SEAT WIDTH No Taper FOOTREST WIDTH 1.5 Taper (4 3.5 Taper OR A2FE2 V-FRONT END insideinside (Titanium Flip-Back Footrest has 1 of adjustment up and down.) NCO NO OR FOOTREST WIDTH above SEAT BACK TYPE/PUSH HANDLES/SEAT BACK HEIGHT SEAT BACK TYPE NCO (Titanium back will match Frame Finish. Not available with Bolt-On Push Handles.) $225 NCO TISHAFT BACK RELEASE BARS Aluminum Titanium $65 $65 PUSH HANDLES NCO (Requires Tension Adjustable by Straps Back Upholstery.) $100 (Requires 4 Deep Backrest Rigidizer Bar. Not available with Ti Back.) $175 (Requires 4 Deep Backrest Rigidizer Bar. Not available with Ti Back. Limited range with Depth Adjustable Back.) $295 SEAT BACK HEIGHT Push Handles Short Medium Tall Set at: (Use 1/2 increments) None Set at: Set at: Set at:
5 FRAME MEASUREMENTS AVAILABLE ON ALL BACKS NCO (Not Available with 19 or 20 Seat Depths. Seat Depths of allow 2 of rearward adjustment. Not available with Tension Adjustable by Straps Seat Upholstery, Carbon Fiber Side Guards or Desk Arms. Height Adjustable Push Handles have a limited range with Depth Adjustable Back.) NCO (The Standard Rigidizer Bar height is 5 above the Seat Sling for a short, 6-1/4 for a medium and 10-1/4 for a tall. Custom Height Rigidizer Bar must be at least 4-1/2 above Seat Sling or 5-3/4 above Seat Sling when used with Swing Away Tubular Armrests. Maximum Height is 3 less than Lowest Seat Back Height.) $150 Page 5 of 9 SEAT BACK ANGLE NCO CENTER OF GRAVITY REAR WHEEL SPACING 1 2 CAMBER /CAMBER TUBES $75 Titanium Camber Tube (Not available with Power Adaptable Frame.) $175 Carbon Fiber Camber Tube (Not available with Power Adaptable Frame or more than 6.) $175 Additional Aluminum Camber Tube $100 Additional Titanium Camber Tube $225 Additional Carbon Fiber Camber Tube $225 Additional Spacers to Increase Rear Wheel Spacing NCO FRONT WHEELS (Not available with Slipstream Fork.) (Not available with Slipstream Fork.) $70 (Available with Slipstream Fork only.) $155 (Not available with Slipstream Fork.) NCO (Not available with Slipstream Fork.) $70 OR $125 OR $165 $80 (Not available with 90º Front Angle or with Slipstream Fork.) NCO OR (Not available with 90º Front Angle.) $145 OR (Not available with 90º Front Angle.) $185 (Not available with 90º Front Angle.) $80 (Not available with 85º or 90º Front Angle or with Slipstream Fork.) NCO OR (Not available with 85º or 90º Front Angle or with Slipstream Fork.) $165 (Not available with 85º or 90º Front Angle or with Slipstream Fork.) $65 OR (Not available with 85º or 90º Front Angle or with Slipstream Fork.) $165 (Not available with 85º or 90º Front Angle or with Slipstream Fork.) $195 (Must Choose Wheel Size Above. Not available with Slipstream Single-Sided Fork.) -$20 FRONT FORKS A2FK1 A2FK2 (Not available with Power Adaptable Frame.) $150 (Available in Black anodize only. Not available with Heavy Duty Edition.) $425 E1015 A2TFS1 (Not available with Frog Legs ) $50
6 REAR WHEELS See Rear Seat Height Ranges chart on Page 3 for Rear Seat Height limitations TM (Not available with Titanium Quick Release Axles or Heavy Duty Edition.) (Requires 15 minimum Seat Depth.) (Requires 15 minimum Seat Depth.) (Not available with Titanium Quick Release Axles, Airless Inserts or Solid Tires.) $100 (Not available with Titanium Quick Release Axles.) $250 (Requires 15 minimum Seat Depth.) (Requires 15 minimum Seat Depth.) (Not available with Titanium Quick Release Axles.) $895 (Requires 15 minimum Seat Depth.) Red $695 (Requires 15 minimum Seat Depth.) (Requires 15 minimum Seat Depth Not available with Titanium Quick Release or Quad Release Axles.) Red $895 (Requires 15 minimum Seat Depth.) (Requires 15 minimum Seat Depth Not available with Titanium Quick Release or Quad Release Axles.) (Not available with Titanium Quick Release Axles or Heavy Duty Edition.) $1,195 (Requires 15 minimum Seat Depth.) (Not available with Short Tabs, Titanium Quick Release Axles, Quad Release Axles or Spoke Guards or Heavy Duty Edition.) $50 (Must choose Wheel Size and Tire Type below.) -$50 AXLES A2AXL1 A2AXL2 (Not available with TiLite High Flange Hub, TWIN-STAR Exchange, DASH, SHADOW, Mags, 26 (590) Spinergy SPOX or LX Rear Wheels or Power Adaptable Frame.) $225 A2AXL3 Quad Release (Not available with Mags or 26 (590) Spinergy Spox or LX Rear Wheels.) $125 Page 6 of 9 PNEUMATIC REAR TIRES A2RTR1 (Not available with 25 (559) Rear Wheels.) A2RTR2 (Not available with DASH Rear Wheels.) $80 E2213 A2RTR3 (Standard with 25 (559) Rear Wheels.) A2RTR4 NCO $95 Red $95 (Requires TiLite Wheel with High Flange Hub.) $95 (Requires TiLite Wheel with High Flange Hub or Spinergy SPOX or Spinergy LX Rear Wheels.) $95 $125 SpeedRun $125 SOLID REAR TIRES (Not available with DASH Rear Wheels.) $70 A2RTR11 $75 A2RTR13 $95 A2RTR15 $95 HANDRIMS Handrims by OUT-FRONT A2RIM1 Titanium (Not available with Mags, 20 (451) or 22 (501) Rear Wheels, or 24 (540) Knobby tires.) A2RIM12 Satin Finish $400 A2RIM13 Polished Finish $550 (Not available with 22 (501) Mags or 20 (451) Rear Wheels.) A2RIM14 (Not available with Short Tabs.) $325 A2RIM15 (Not available with Short Tabs.) $370 $300
7 HANDRIMS (Not available with 22 (501) Mags or 20 (451) Rear Wheels.) (Not available with Short Tabs.) $355 (Not available with Short Tabs.) $400 $330 (Not available with 22 (501) Mags.) $315 A2RIM11 (Not available with 22 (501) Mags.) $340 (Not available with 20 (451), 22 (501) or 26 (590) Rear Wheels or Mags.) $295 Additional Handrims (Available only on 24 (540) and 25 (559) Spinergy LX Rear Wheels. Please allow an additional 2-3 weeks delivery.) $525 A2RIM5 $95 (Not available with 20 (451), 22 (501) or 26 (590) Rear Wheels or Mags.) $305 -$15 Tab Length Long Tabs (Not available with Mags or The Natural-Fit Handrims with Thumb Grip.) $15 Page 7 of 9 WHEEL LOCKS Push (Available with.75 to 1.5 Rear Wheel Spacing only) NCO Pull (Available with.75 to 1.5 Rear Wheel Spacing only) NCO $75 E0961 $125 $150 Push OR Pull $145 $75 E0961 BACK UPHOLSTERY (Not available with Fold-Down Push Handles.) (Required with Aluminum Fendered Side Guards and Fold-Down Push Handles.) Padded Nylon (Not available with Ultrasuede Backrest Stripe.) $300 (Not available with AIR Breathable Back Upholstery.) $90 Ride Designs (Black Only. Not available with Fold-Down Push Handles. See Chart Below.) NCO CORBAC SEAT WIDTH/BACK HEIGHT AVAILABILITY CHART Rear Seat Width Seat Back Height $300 E2611 $455 E2611 SEAT UPHOLSTERY A2SUP1 (Not available with Tapered Seat Black only.) isleeve (Not available with 10 to 13 Rear Seat Width or Seat Depth.) $50 A2SUP2 (Standard Front Seat Width (Seat Taper) of 1.5 and 2.5. Black only. Not available with Depth Adjustable Back.) $150 A2SUP3 (Not available with 10 or 11 Rear Seat Width.) $245 E2618 NCO SEAT CUSHIONS $95 StimuLITE (Please allow an additional 2-3 weeks delivery. Black upholstery only.) $525 E2603 (Please allow an additional 2-3 weeks delivery. Black upholstery only.) $525 E2603 (Please allow an additional 2-3 weeks delivery. Black upholstery only.) $525 E2624 (Please allow an additional 2-3 weeks delivery. Black upholstery only.) $625 E2609 VARILITE Evolution (Black only, see chart below.) $525 E2622 VARILITE Zoid (Black only, see chart below.) $525 E2622
8 TiLite Page 8 of 9 VARILITE SEAT CUSHION AVAILABILITY CHART Seat Depth Seat Width VARILITE Evolution VARILITE Zoid SIDE GUARDS (Not available with Ride Designs Corbac back support.) $85 Aluminum Rigid Removable Small OR Std $175 Small OR Std $185 Fold Down Rigid Small OR Std $295 (Available with 24 and 25 Rear Wheels. Requires Rear Seat Height of 14.5 to 18.5.) $295 Carbon Fiber (Not available with Depth Adjustable Back/Frame.) Rigid Removable Small OR Std $270 Small OR Std $280 Fold Down Rigid Small OR Std $400 $395 Available on Aluminum and Carbon Fiber Non-Fendered Side Guards (Not available with Cloth.) $275 ARMRESTS OR 11 to 14 (Not available with Depth Adjustable Back/Frame.) $195 E0973 OR $275 E0973 (Not available with Depth Adjustable Back/Frame. Requires 14 minimum Seat Depth.) $295 E0973 OR 12 to 15 OR Full Length Pad (14 ) $340 E0973 (Not available with Depth Adjustable Back/Frame. Requires 15 minimum Seat Depth ) OR 12 to 15 OR Full Length Pad (14 ) Available on all Armrests A2ARM5 $95 SEAT BELTS $45 E0978 $85 E0978 (Not available with 19 or 20 Rear Seat Widths.) $155 E0978 (Not available with 19 or 20 Rear Seat Widths.) $155 E0978 (Not available with 19 or 20 Rear Seat Widths.) $155 E0978 (Not available with 19 or 20 Rear Seat Widths.) $120 E0978 CALF STRAP $25 K0038 $35 K0038 $75 K0038 BACK PACK $50 $65 SEAT POUCH $40 $45
9 TiLite Page 9 of 9 SPOKE GUARDS (Not available with Mags.) $115 K0065 (Not available with Mag Rear Wheels.) $275 K0065 (Not available with Mag Rear Wheels.) $275 K0065 (Not available with Mag Rear Wheels.) $275 K0065 ANTI-TIPS A2TIP1 $135 E0971 A2TIP2 $245 E0971 ACCESSORIES 12 to 14 OR (Requires Armrests.) $250 E0950 $125 $90 $75 $195 E2207 Small Medium $25 A2TIP5 (Requires that Seat to Footrest Measurement be at least 3 shorter than Front Seat Height. Not available w/ Titanium Flip-Back Footrest.) $145 $25 A2AFP1 4 Logo Patch Navy $90 A2AFP2 Name Tape Patch Navy $90 A2AFP3 $90 DESIGNS UNLIMITED GENERAL Get the latest order forms at tilite.com Adobe Legs NOTES QUOTE THIS CHAIR ORDER THIS CHAIR
Additional Front Wheel Options Not Shown FW1 3 x.75 Micro-Caster FW14 4 x.75 Plastic Wheel w/poly Tire FW3 4 x.75 Light-Up Micro-Caster
front wheels FW2 3 x.75 Light-Up Micro-Caster FW23 3 x1.5 Billet Aluminum Micro Caster w/soft Roll Tire FW19 4 x.75 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire - Silver Hub OR Black Hub FW20
More informationAddress: 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:
More informationSling Position. Push Handle. q Omit Push Handles N/C q Standard Push Handles 53 q Fold Down Push Handles 80 q Bolt-On Push Handles 109
Effective 05/07/2014 Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: q Rogue XP 1825 Rogue Width Grow-able Frame. 275 lb weight capacity. Maximum initial : 16. q Rogue 1495 Rogue Standard
More informationClick 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
More informationClick 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
More informationMEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
Canada MEDmobility 5711- Calgary Trail NW Edmonton AB T6H 2K1 P: 780-437-3300 F: 780-430-9381 www.medmobility.ca Company: Account Number: Date: Quote PO Number: RTS: AADL #W154 Effective 10/01/2017 Ship
More informationORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S C H U M P - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
More informationAddress: STD TWANO5 Sapphire TWANO3 Red Pepper TWANO6 Burnt Orange TWANO7 Sub-Lime TWANO8 Ultraviolet $150
Effective February 1, 2015 (New Items in Red) Page 1 of 7 DEALER INFORMATION RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email: SHIP TO INFORMATION Mark For: Name: Ship Via: Sales
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Page 1 of 6 DEALER INFORMATION Client Name: Dealer: Contact No: Address: TiLite Information Promo Code: City: State: PC: Ship Date: Order #: Phone: Fax: Please Email order to orders.au@permobil.com or
More informationInternational TiLite Z-Series Order Form
Effective January 2 nd, 2019 (New Items in Red) DEALER INFORMATION International TiLite Z-Series Order Form MONO-TUBE RIGID FRAME RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email:
More informationMASS Script Form. Frame. Backrest. Seat Depth
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Order Effective 01/10/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Rogue XP K0005, E1235
More informationMASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Form Effective 05/07/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Tsunami ALX K0005 Charge
More informationOrder Form SHIP TO INFORMATION. TiLite Information: Promo Code: City: State: Zip: Dealer: Account #: RTS: Phone: PO: Ordered By:
Effective April 1, 2019 (New Items in Red) DEALER INFORMATION MONO-TUBE RIGID FRAME RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email: SHIP TO INFORMATION Mark For: Name: Ship
More informationq 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.
Funder: Order Number: Date: q Quote q PO Number: Therapist: Marked For: Catalyst 5 K5-CAT5-ALI 136kg weight capacity Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth
More informationOrder Form SHIP TO INFORMATION. TiLite Information: Promo Code: City: State: Zip: Dealer: Account #: RTS: Phone: PO: Ordered By:
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Canada Patent Pending AADL #W157 Effective 10/01/2017 Company: Ship To: Account Number: Date: Quote PO Number: RTS: Marked For: Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time
More informationThis form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Canada AADL CAT # 151 Effective 10/01/2018 Company: Account Number: Date: q Quote q PO Number:
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C O L O U R S S PA Z Z - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
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More informationAPEX 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Height available +- 1/4" Caster sizes. 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 APEX ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
More information4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)
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 : PO : Vendor : CUSTOM TECHNOLOGIES LIMITED Date
More informationAPEX 4.6. FRONT Seat-to-floor height Caster sizes Height available +- 1/4" ORDER FORM - International. 3" Caster. Specify desired height:
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:*
More information4.6. 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:*
More informationZippie Zone July 2018 EIRZ1
Zippie Zone July 2018 EIRZ1 Date: SUBMITTING F: Quote Order Dealer Acct #: Dealer: PO#: Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV: PC: Address: Dealer Phone: ( ) Fax: ( ) Address:
More informationSTD +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:*
More informationQuickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
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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:*
More informationSerial Number: Manufacturing Date: /20
Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 csrcanada@sunmed.com www.sunrise.ca Distributor Name: Dealers Name: Contact
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More information3 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.
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More informationMASS Script Form. 160 Kg Weight Capacity Charge. Transit Option. 136 Kg maximum weight capacity. Not available with Removable Seat Pan.
MASS Script Form Australian Order Form Effective 05/07/2014 Company: Account Number: Date: Quote PO Number: RTS: Marked For: Ship To: Address: City: State: Zip: Phone: Email/Fax: Catalyst 5Vx K0005 Charge
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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 VELOCE ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
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Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 csrcanada@sunmed.com www.sunrise.ca Distributor Name: Dealers Name: Contact
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Quantum Rehab Discount: Terms: Freight: Taken By: DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered
More informationKüschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone)
Manual Wheelchair Retail Prescription Form UltraLight061216 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com JANUARY 2017 Online spares available at: www.invacare.co.uk Account No : Built
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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
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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
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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
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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 4.8 Helio A6 ORDER FORM - INTERNATIONAL P.O.
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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 4.7 Helio A6 ORDER FORM - CANADA P.O. number:*
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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.
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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:
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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 P.O. number:* Date: Ship to:* Company Name:*
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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
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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 4.8 Helio A7 - FiveDay ORDER FORM - CANADA P.O.
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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 4.8 P.O. number:* Date: Ship to:* Company Name:*
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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 4.7 Helio A7 - FiveDay ORDER FORM - CANADA P.O.
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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 4.8 Helio C2 ORDER FORM - CANADA P.O. number:*
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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 4.8 MOVE ORDER FORM - CANADA P.O. number:* Date:
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