Bora. Standard Base Price 4,100. Standard Features SEAT DEPTHS

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1 Power Wheelchair Retail Prescription Form BORAMOD Tel: Fax: JANUARY Online Spares available at: Customer Ref : Account No : Contact No : Delivery Address : Order Qty : Bora Order Date : Standard Features Modulite highly adjustable seating system Telescopic adjustable Seat Widths from 330mm 530mm (13" 21") with an additional 50mm, (2") by arms Seat Depths 410mm 510mm Stepless Adjustment (16" 20") Tension Adjustable backrest Standard T Armrests, detachable with Short armpad Manual settable seat Tilt (0 20 ) Manual settable backrest Recline (0 30, in 3.75 steps) 80 hangers with fixed footplate LiNX Control REM110 with standard bracket Choice of 2 Chassis Colours, 7 Body Shroud Colours, 3 Rim colours 200mm x 45mm (8" x 1.175") Puncture proof PU foam sealed, Black castors 318mm x 57mm (12.5" x 2.25") Puncture proof solid inlay Black drive wheels Rear suspension (3 options) 6 km/h (4mph) 2 Pole Motors and 50 Ah Batteries 8A ( V) Charger Bolt on or quick release anti tippers 4 Point tie down system Lapbelt with autolock (adjustable both sides) Standard Base Price 4,100 * Configurations may vary from the image shown X Please make your selection with a cross in the box Standard feature Free of Charge Customer weight = Kg Code Description Retail ASM0064 Bora Basic Model 4,100 ASZ0064 Bora Special Basic Model PLEASE COMPLETE DETAILS AT THE END OF THE FORM POA SEATING TYPE ASM2100 X Modulite Seating Unit SEAT FRAME AND SEAT PLATE ASM2111 Telescopic Seat Frame with metal seat plate (with stepless adjustment on armrests, legrests and backrest) MODULITE SEAT SIZE SETTING CHART: SEAT DEPTHS ASM2132 (16") 410mm ASM2134 (18") 460mm ASM2136 (20") 510mm 330mm* (13") ASM mm (15") SEAT WIDTHS ASM mm (17") ASM mm (19") ASM mm (21") Page 1 of 8

2 *330mm (13") seat width achieved on a 380mm seat frame (2121) with inrigged armrests (2183) 1. Seat depth 410mm: cannot combine T-Armrests (2191) with flexible lapbelt mount (2113) 2. Seat width 530mm (2124) not possible in combination with following armrests (2192/3) 3. Modulite Teen seating available, seat width and depth from 305mm (12") - See New form SEAT OPTION ASMSWO "H" Frame Interface Kit 395 SEAT CUSHION (sizes according to seat frame settings) ASM2142 Matrx Flo-tech Lite 99 ASM2143 Matrx Flo-tech Contour Visco Not available with seat width 380mm, 530mm, seat depth 510mm 99 ASM2147 Matrx Libra, 90mm thick Not available with seat width 530mm with 410mm seat depth 345 ASM2144 Matrx VI (Mesh fabric) Not available with seat width 530mm with 410mm seat depth 362 ASM2140 Without seat cushion BACKREST SUPPORT ASM2162 Backposts 540mm (Tall) Must be selected for flex3 adjustable backrest ASM2163 Backposts 480mm (Short) Not available with flex3 adjustable backrest PUSH HANDLES FOR BACKPOSTS ASM2107 Backposts WITH push handles ASM2108 ASM2171 ASM2179 Backposts WITHOUT push handles Push handles will be cut down on the vertical section. BACKREST UPHOLSTERY / CUSHION Not available with attendant, dual, matrx backrest's, headrest (1495), tension adjustable backrest (2171) in combination with a headrest. Not available with laterals, headrest option 1496, chin control Not available with flip up, following armrests, chin remote, laterals with rigid pad ASM2172 Flex3 adjustable Backrest Plates (without Backrest Cushion) 198 ASM2173 Flex3 adjustable Backrest Plates with Laguna Backrest cushion 321 ASM2174 ASM2175 ASM2176 Basic Tension Adjustable, (540mm or 480mm upholstery height) Straps easily accessible and adjustable from the rear, Black fabric only Flex3 Tension Adjustable (540mm - 480mm) Black Dartex only Matrx Posture Back, height 400mm (Mesh fabric) Matrx Posture Back, height 500mm (Mesh fabric) Matrx Elite Back, height 500mm (Mesh fabric) Not available with laterals, 530mm seat width, headrest option 1496 Not available with laterals, 530mm seat width, headrest option 1496 Not available with laterals, 530mm seat width, headrest option 1496, seat width of 380mm 2121 in combination with flip up or following armrests ASM2177 Matrx Elite TR Back, height 500mm (Mesh fabric) Not available with laterals, 530mm seat width, headrest option ASM2178 Matrx Elite Deep Back, height 500mm (Mesh fabric) Not available with laterals, headrest option ASM2170 Without Backrest Upholstery Not available with laterals, headrest option 1496 UPHOLSTERY TYPE ASM2151 Black fabric ASM2152 Black Dartex ASM2155 Black Spacer fabric ARMRESTS (Pair) ASM2191 T-Armrest Standard Range of adjustment from seat plate 245mm to 315mm ASM2181 T-Armrest Extended height Range of adjustment from seat plate 295mm to 365mm 32 ASM2183 In-rigged Armrests (reduces seat width by 25mm each side) ASM2193 Flip-up Armrest (height and depth adjustable) (height adjustable from 230mm - 360mm) Not available with laterals 51 ASM2192 Following Armrest (height adjustable from 230mm - 300mm) Not available with laterals 146 ASM2194 Following Armrest (height adjustable from 300mm - 360mm) Not available with laterals 146 ARMPAD (Pair) ASM2195 Short Armpad (325mm) ASM2196 Long Armpad (375mm) Not available with seat depth 410mm ASM2197 Long Ergonomic Armpad (397mm) Not available with seat depth 410mm ASM2199 Soft Armpad (REA Azalea Wide Pad) Not available with seat depth 410mm 76 Page 2 of 8

3 HIP SUPPORTS, Multi adjustable LH (for flip up and following armrests only) ASM2184 SMALL 140mm x 100mm ASM2186 MEDIUM 230mm x 100mm ASM2188 LARGE 330mm x 100mm HIP SUPPORTS, Multi adjustable RH (for flip up and following armrests only) ASM2185 SMALL 140mm x 100mm ASM2187 MEDIUM 230mm x 100mm ASM2189 LARGE 330mm x 100mm EXTENDED HEIGHT (+2") MOUNTING HARDWARE FOR HIP SUPPORTS NEW! ASM2165 Extended height mounting hardware for hip supports (8.1" / 206mm high) SEAT ACCESSORIES HEADREST / NECKREST (Dartex covered) - Adequate headrest option must be selected ASM1350 Neckrest: height and depth adjustable 64 ASM1432 Headrest: height, depth and sideways adjustable 179 ASM1427 Headrest with cheek support: height and depth adjustable 179 ASM2323 ASM2324 ASM2322 ASM2325 ASM2326 ASM2327 Elan Standard Pad 150mm (6") wide with standard cover Elan Standard Pad 255mm (10") wide with standard cover Elan Standard Pad 355mm (14") wide with standard cover Elan Occipital Pad 230mm x 180mm (9" x 7") with standard cover Elan Occipital Pad 305mm x 200mm (12" x 8") with standard cover Elan 4 Point Headrest Pad 280mm x 255mm (11" x 10") with standard cover, ASM1496 All bracketry as option 1432 without headrest cushion Not available with chin control ASM1495 Push bar dia. 22mm in conjunction with telescopic seat frame / backposts, No Headrest - no mounting hardware. Not available with chin control 350 LATERAL SUPPORT (Pair) ASM1446 Rigid pad (Azalea type, Dartex) 133 ASM1445 Multi-adjustable pad (Azalea type, Dartex) 133 SEAT ADJUSTMENTS SEAT LIFTER / SEAT TILT Tilt Range Seat Height Selection ASM1091 Manually settable mm ASM1092 Powered basic mm 320 ASM1092 ASM2139 Powered Basic with increased seat height mm 320 Increase in seat height to facilitate rearward adjustment of the seating ASM1093 Powered centre of gravity shift mm 825 ASM1094 Seat Lifter with centre of gravity shift (300mm rise) mm - 480mm 1,400 BACKREST RECLINER ASM0975 Manual Settable Recliner (0-30 in 3.75 steps) Foldable ASM0977 Powered Recliner (0-30 ) Foldable Page 3 of 8

4 LEGREST / FOOTREST FOOTREST HANGER TYPE (Pair) ASM0526 Standard 80 hangers Only with fixed footplate, adapt footplate (0513) ASM0529 Manually height adjustable, (Rea Style) Only with fixed footplate, adapt footplate (0513) 133 ASM0503 VARI F Angle adjustable with tools 0-70, length 290mm - 460mm 95 ASM0533 VARI A : Angle adjustable with hand wheel 0-70, length 290mm - 460mm Not available with fixed footplates 185 ASM0531 ADE Powered : Angle adjustable powered by joystick, 0-80, length 290mm - 460mm Not available with fixed footplate, footboard 530 ASM0501 Without Hanger FOOTPLATE TYPE (Pair) ASM0512 Fixed Footplate ASM0504 Angle adjustable Footplate 25 ASM0513 Angle and depth adjustable Footplate (Adapt) 94 ASM0522 Angle adjustable Footboard 121 LiNX PRIMARY CONTROLS (SECTION 1) LiNX PRIMARY REMOTE & BRACKET ASM2201 REM110 Drive only Not available with lights ASM2203 REM211 Drive & Actuators Not available with lights ASM2204 REM216 Drive, Actuators & Lights 120 ASM2205 REM400, touch-screen interface, Built in Bluetooth HID 270 ASM2270 Assignable Toggle Switch Module for REM400 (as default set to left ON / OFF, right speed dial) 250 ASM1207 Standard Bracket RH ASM1208 Standard Bracket LH ASM1707 Swing Away RH 105 ASM1708 Swing Away LH 105 ASM2227 Bracket RH mounted for Attendant 50 ASM2228 Bracket LH mounted for Attendant 50 ASZ2239 Individual mounting option per request (Special) - Requires additional information / specification POA LiNX REM500 REMOTE & BRACKET (Secondary User input required 2231, 2232, 2229) ASM2206 REM500, without joystick for alternative access, Built in Bluetooth HID' 615 ASM2209 Swing away RH, multi-adjustable ASM2210 Swing away LH, multi-adjustable ASM2213 Centre mount, swing away to RH, Nucleus Not available with a tray ASM2214 Centre mount, swing away to LH, Nucleus Not available with a tray ASZ2239 Individual mounting option per request (Special) - Requires additional information / specification POA Page 4 of 8

5 LiNX DUAL CONTROL & BRACKET: CAN ONLY BE SELECTED IN ADDITION TO LiNX USER CONTROL ASM2220 Dual Control REM050 Drive only 313 ASM2219 Compact Dual Control (ACU200) Not available with REM110 drive only remote 313 ASM1207 Standard Bracket RH ASM1208 Standard Bracket LH INVACARE LiNX IDC DUAL CONTROL & BRACKET ASM2245 Invacare IDC Dual control Not available with REM110 drive only remote 595 ASM1221 IDC Dual control Detachable Bracket RH ASM1222 IDC Dual control Detachable Bracket LH *If no specialist are required please move to the frame colour section on page 7* LiNX SPECIALIST CONTROLS (SECTION 2) LiNX - COMPACT REMOTES & BRACKET (Requires Primary Remote REM400 or REM500) ASM2231 Proportional Compact Remote DLX-CR ASM2232 Proportional Compact Remote Low Force DLX-CR-400LF 875 ASM2207 RH Mount ASM2208 LH Mount ASM2213 Centre Mount swing away to RH (Nucleus) Not available with a tray ASM2214 Centre Mount swing away to LH (Nucleus) Not available with a tray ASZ2215 Individual mounting option per request (Special) - Requires additional information / specification POA LiNX CHIN CONTROL & BRACKET (Requires Primary Remote REM400 or REM500) ASM2229 Proportional Chin Joystick (ASL138) Not available with bag hooks 1,535 ASM1289 Swing Away Bracket RH side manual (ASL628) (Requires ELAN Headrest) ASM1288 Swing Away Bracket LH side manual (ASL628) (Requires ELAN Headrest) ASM1287 Swing Away Bracket RH side powered Has to be mounted on opposite side of attendant bracket, cane holder, mirror, tray 1,990 ASM1286 Swing Away Bracket LH side powered Has to be mounted on opposite side of attendant bracket, cane holder, mirror, tray 1,990 HEAD CONTROL (with ATOM technology) (Requires Primary Remote REM400 or REM500) ASZ2230 Head Control with ultrasonic proximity sensors (ATOM, ASL104) with standard wings M3 3,300 ASZ2247 Head Control with ultrasonic proximity sensors (PROTON, ASL104P) with PROTON wings 3,970 FOUR-SWITCH PROXIMITY ARRAY (with ATOM technology) ASZ2257 Four-Switch Proximity Array (ASL106) Not available with bag hooks 5,250 ASZ2275 Centre Mount, swing-away to RH, Nucleus (includes Eclipse Tray ASL619, 360mm x 180mm) ASZ2276 Centre Mount, swing-away to LH, Nucleus (includes Eclipse Tray ASL619, 360mm x 180mm) ASZ2215 Individual mounting option per request (Special) - Requires additional information / specification POA WIRELESS ACCESSORIES FOR ATOM ASZ2249 Wireless Triple Switch Receiver (ASL557-3) (Sub D plug) 270 ASZ2250 Wireless Mouse Emulator (ASL558) 648 MICRO EXTREMITY CONTROL (Requires Primary Remote REM400 or REM500) ASZ2233 MEC Proportional Joystick (Micro Extremity Control) Not available with bag hooks 3,292 ASZ2235 Tray Mount RH (ASL603, 100mm x 150mm) ASZ2236 Tray Mount LH (ASL603, 100mm x 150mm) ASZ2213 Centre Mount, swing away to RH, Nucleus ASZ2214 Centre Mount, swing away to LH, Nucleus ASZ2241 Centre Mount, swing away to RH, Nucleus (incl. Tray ASL603, 100mm x 150mm) ASZ2242 Centre Mount, swing away to LH, Nucleus (incl. Tray ASL603, 100mm x 150mm) ASZ2215 Individual mounting option per request (Special) - REQUIRES ADDITIONAL INFORMATION / SPECIFICATION POA Page 5 of 8

6 HEAVY DUTY REMOTE JOYSTICK (Requires Primary Remote REM400 or REM500) ASZ2240 Proportional Heavy Duty Remote Joystick with mode switch (ASL133) Not available with bag hooks 1,835 ASZ2235 Tray Mount RH (ASL603, 100mm x 150mm) ASZ2236 Tray Mount LH (ASL603, 100mm x 150mm) ASZ2213 Centre Mount, swing away to RH, Nucleus ASZ2214 Centre Mount, swing away to LH, Nucleus ASZ2241 Centre Mount, swing away to RH, Nucleus (incl. Tray ASL603, 100mm x 150mm) ASZ2242 Centre Mount, swing away to LH, Nucleus (incl. Tray ASL603, 100mm x 150mm) ASZ2215 Individual mounting option per request (Special) - REQUIRES ADDITIONAL INFORMATION / SPECIFICATION POA LiNX 10-WAY SWITCH & BRACKET ASM Way Switch DLX-SW10-A for direct Powered Seating Access (includes loom to connect + additional jack for mode switch) 400 ASM2217 Bracket RH, mounted for User ASM2218 Bracket LH, mounted for User ASM2227 Bracket RH, mounted for Attendant 50 ASM2228 Bracket LH, mounted for Attendant 50 LiNX ACCESSORIES ASM2252 Loom providing jack sockets for 10 way switch and buddy button (Mode) 80 LiNX USB CHARGER PORT & BRACKET ASM2253 USB Charger Port DLX-USB02-A Not available with Bodypoint pelvic belts 126 ASM2207 RH Mount ASM2208 LH Mount FURTHER LiNX COMPONENTS / ACCESSORIES (SECTION 3) ASM2300 To be enclosed only - not mounted to the chair ASZ2301 To be connected and programmed (Special) POA BUDDY BUTTONS (Accessory loom 2252 required if no REM400 or REM500 is selected) ASM1685 Red Buddy Button 70 ASM1686 Yellow Buddy Button 70 ASM1687 Green Buddy Button 70 ASM1690 Blue Buddy Button 70 EGG SWITCH (Accessory loom 2252 required if no REM400 or REM500 is selected) ASM2254 Egg Switch, black 70 PIKO BUTTONS (Accessory loom 2252 required if no REM400 or REM500 is selected) ASM1711 Red Piko Button 125 ASM1712 Yellow Piko Button 125 ASM1713 Green Piko Button 125 ASM1714 Orange Piko Button 125 ASM1715 Blue Piko Button 125 ASM1716 Black Piko Button 125 TOGGLES / BUTTONS ASZ2261 Stereo Toggle - direct control for Tilt only 213 ASZ2262 Stereo Button - direct control for Tilt only 204 ASZ2263 Four-Way Toggle - direct control for Tilt & Recline 266 ASZ2264 Four-Way Button - direct control for Tilt & Recline 284 ASZ2207 RH Mount ASZ2208 LH Mount ASZ2225 Without Mounting BODYPOINT JOYSTICK KNOBS NEW! ASM2721 3" wide U-Shaped, Joystick Handle 57 ASM2722 4" wide U-Shaped, Joystick Handle 57 ASM2723 Wide Rubber Dome, Joystick Handle 57 ASM2724 Grooved Mushroom Joystick Handle 57 Page 6 of 8

7 REMOTE STOP SWITCH ASZ2258 Remote Stop Switch (ASL504) 832 DRIVE UNIT OPTIONS FRAME COLOUR ASM0228 Black ASM0252 Arctic White BODY SHROUD COLOURS ASM0242 Pearl Night Blue ASM0243 Metallic Silver ASM0224 Black ASM0204 Transparent Cherry Red ASM0222 Arctic White ASM0248 Grasshopper Green ASM0279 Sunshine Yellow RIM COLOUR ASM0290 Rim colour White Not available with solid PU-foam castors ASM0292 Rim colour Silver ASM0291 Rim colour Black Not available with solid PU-foam castors CASTORS ASM0835 9" Castor, Pneumatic, Black (non-marking) ASM0836 9" Castor, Puncture proof solid inlay, Black (non-marking) ASM0828 8" Castor, Puncture proof solid PU-foam, Black (non-marking) Only available with Silver rim colour DRIVE WHEELS ASM mm x 57mm (12.5" x 2.25") Pneumatic, Black (non-marking) ASM mm x 57mm (12.5" x 2.25") Puncture proof solid inlay, Black (non-marking) PERFORMANCE OPTIONS SUSPENSION ASM1264 Rear suspension, standard (STANDARD Silver Spring) ASM1265 Rear suspension, strong (STRONG Black Spring) (must be chosen with the riser) Required with lifter option (1094) and with 30 tilt ASM1220 Rear suspension, extra strong (Extra STRONG Spring Black with dampeners ) MOTOR TYPE ASM km/h (2mph) ASM km/h (4mph) ASM km/h (6mph) includes LED light system with indicators and rear wheel fender (1437 and 1417) 397 BATTERY ASM1257 X 50 Ah (Gel) PERFORMANCE ACCESSORIES G-TRAC G-trac ensures the powerchair takes the intended direction as indicated by the user control, without the ASM1215 need for continual correction by the client on uneven 653 or sloping terrain. CHARGER ASM1343 OptiCharge Charger 8A ASM1313 OptiCharge Charger 10A ( V) Charging time will be 20% faster 120 SAFETY OPTIONS ANTI-TIPPERS ASM1234 Bolted on Anti Tippers ASM1201 Quick release Not available with seat riser LIGHTS ASM1437 LED light system with Indicators (Already included in ASM km/h motor) 360 ASM1254 Without Light system SAFETY ACCESSORIES KERB RIDER ASM1244 Central Kerb Rider (with parking position) Not available with a footboard 168 TRANSPORTATION KIT ASM1494 X 4-Point tie-down (Tested version for using wheelchair as a vehicle seat according to ISO :2001) (Adequate headrest is compulsory) Q-Straint : Compatible with Q -Straint QLK-150 drive from system (occupied) no modifications required and can be fitted at a later date Page 7 of 8

8 LAP BELT ASM1329 Lapbelt (adjustable both sides) fitted to base of backrest ASM2113 ASM2701 ASM2702 ASM2703 ASM2704 ASM2705 ASM2706 Lapbelt (adjustable both sides) adjustable mounting on seat rail extrusion BODYPOINT PELVIC BELTS (Includes mounting kit) Evoflex Pelvic Stabilizer, Rehab Latch size L (padded length 620mm) Evoflex Pelvic Stabilizer, Rehab Latch size M (padded length 460mm) 2-Point Hip Belt, Centre pull - push button, Cinch mount size L (padded length 620mm) 2-Point Hip Belt, Centre pull - push button, Cinch mount size M (padded length 460mm) 2-Point Hip Belt, Dual pull, Side release button, Cinch mount size L (padded length 620mm) 2-Point Hip Belt, Dual pull, Side release button, Cinch mount size M (padded length 460mm) REAR VIEW MIRROR - Must be selected with 10 km/h Motors Not available in combination with 410mm seat depth (2132) and T-armrest (2191) Not available with seat width 380mm, 430mm, seat depth 410mm, hip supports Not available seat width 480mm, 530mm, seat depth 410mm, hip supports Not available with seat width 380mm, 430mm, seat depth 410mm, hip supports Not available seat width 480mm, 530mm, seat depth 410mm, hip supports Not available with seat width 380mm, 430mm, seat depth 410mm, hip supports Not available seat width 480mm, 530mm, seat depth 410mm, hip supports ASM1415 Rear view Mirror RH 33 ASM1339 Rear view Mirror LH 33 ACCESSORIES BAG HOOKS ASM2128 Bag Hooks (Max load up to 6 kg = impact on max user weight) Not available with flex3 backrest 2172 / 2173, attendant brackets, dual control 61 LUGGAGE RACK ASM1438 Luggage rack Only available with manual tilt 261 CANE HOLDER (in combination with attendant bracket or dual control the cane holder has to be mounted on the opposite side of the remote) ASM1312 Cane Holder RH 33 ASM1363 Cane Holder LH 33 FENDER ASM1417 Fender for rear wheels (mandatory for Lighting system) 83 TRAY - mounted opposite side to controller ASM1404 Swing Away RH 132 ASM1405 Swing Away LH 132 Total Price: Need a different option not on the form? Take a look at our Powerchair Alternative Options form, available as standard Powerchair Alternative Option required: Please refer to our Invacare Unique special order form, for a more complex customer requirement, Available at Special Instructions - Please supply the following information: Name: Phone: Fax: Description of special request (please include relevant option code or part number): Page 8 of 8