The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location)

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1 SAVE RESET FORM PRINT November, 204 BILL TO: The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location) SHIP TO: Dealer Name: Dealer Name: Contact: Contact: Address: Address: City: City: State: State: Zip Code: Zip Code: Phone Number: Phone Number: Fax Number: Fax Number: Address: Address: ORDER / QUOTE INFORMATION Quote/Order Number: Date: P.O. Number: INFORMATION ON THE USER User Name or Number: Knee to Heel: Left: " User Weight: Lbs Seat to Elbow Height: User Height: Feet Inches Seat to Top of Scapula Height: Seat Cushion Thickness: Right: " " " " The order cannot be processed without the following: - A user name or number, the client s measurements and weight - Amysystems is not responsible for configuration or size discrepancies resulting from customer errors on the order form. - Order confirmations will be provided by Amysystems summarizing the items selected. Please review this carefully. - Once the order is shipped, any changes are subject to the returns policy and may be prohibited. POWER BASE SELECTION Wheelchair Model M P R P Amypower Alltrack Mid-Wheel STFH - Tilt & Lift 8 ¾ " (B & C) STFH - Tilt ¾ " (A) 9 " (B & C) 7 " (A) Golden Compass ½ " (B) Quickie Pulse 8 ¾ " (A & C) ¾ " (B) Quickie Rhythm 7 ¼ " (A) Amypower Alltrack Rear-Wheel M F QM70 QM720 Quickie S3 / S4 SE Std. Wide 2 Quickie S525 Narrow Std Wide 2 Quickie P220 / P222 Std. Wide Quickie Freestyle M: 8 ¼ " F: 9 ¼ " (A & C) ¼"-7 ¼" (B) TBA (B & C) TBA (B) 9 ½ " (B & C) 7 ¼ " (A) N/A N/A 8 ½ " (A) TBA (A & C) TBA (B) Quickie Invacare FDX Group 22 Group 24 ½ " (B) Invacare Pronto M9 9 ½ " (A & C) Permobil Model: Invacare TDX SP Invacare Storm 3G Short Long Other Power Wheelchair Base. Specify: 9 ½ " (A & C) 5 ½ " (B) TDX3 TDX4 TDX5 ¾ " (B) Quantum Q Edge Quantum 0 Quantum Z 400Z 8 ¾ " (A & C) ¼ " (B) Quantum R " (B & C) ½ " (B) Quantum J Quantum Rival TBA (B & C) TBA " (B) Innovation In Motion - Frontier V 8 ½ " (A & C) 8 ½ " (A) Innovation In Motion - X8 Extreme 20 " (A & C) 9 " (A) Quantum C - Seat Lift 300 ELECTRONICS (INCLUDED WITH POWER WHEELCHAIR) Standard VSI -Key VSI R-net R-net EL Standard VR2 -Key VR2 INVACARE I.I.M. MK90ACC 5 MK90 MK5-EX MK5-NX MKIV-A MKIV-RII MKTT GTRAC Joystick Type SPJ MPJ Dynamic PRIDE (QUANTUM) 3 Q-Logic Q-Logic NE+ 4 Q-Logic NE -Key VR2 Std VR2 Remote Plus -Key VSI Std VSI Dynamic Shark 3 OTHER MANUFACTURER Specify: Note: For a tilt only with a Long seat pan range up to 22", please replace the 300-B tilt and use the 300-A tilt. Seat to floor height may increase by up to ¾". FOOTNOTES QUICKIE STFH - Tilt 7 " (A) 7 ½ " (A & C) B - 300B Qtronix Delphi Invacare TDX SR Invacare A - 300A STFH - Tilt & Lift 9 ½ " (A & C) Invacare TDX SC (Spree) FOR INTERNAL USE ONLY Wheelchair Model DX2 DX G90 G90T 90A Dolphin P&G R-net (STFH) Seat to floor height is measured at the front of the seat pan with a 0 Pre-Tilt. Base permitting, group 24 batteries can be used to power the wheelchair. 2 For the Quickie S-525 and the P220 / P222 with VSI electronics, they must be tilt ready and equipped with a female Redel "Pigtail" connector in order to obtain 24V power and drive lock-out. When a chair is equipped with an " seat lift and Q-Logic electronics, reduced speed requires 3 going through drive controls. Please select one of these part numbers for reduced speed: SWTJSS, SWTJSD or SWTJSM. 4 The Q-Logic NE is not compatible for through the joystick operation or reduced speed. 5 MK90 is not compatible to be used with power seating options. Requires either the TAM or CLAM interface from Innovation in Motion Specifications are subject to change without notice. 204, Amylior Inc. (November 204) AMYSEAT - USA (Rev. ) Page of

2 Specifications are subject to change without notice. 204, Amylior Inc. (November 204) AMYSEAT - USA (Rev. ) Page 2 of NOTE-IN-HOUSE NOTE-KIT INSTALLATION Factory Installation (The Wheelchair will drop-ship from the manufacturer) Dealer - Ready to Install Kit (For installation by the dealer) POWER OPTIONS & SEATING (300 Lbs User Weight Capacity) The Amyseat is fully adjustable, fully modular, and available with all power options including custom options and specialty controls. SAABA Amyseat - Seat Frame only $,495 SAPTN 7 CG Power Tilt (E002) $4,075 SAPRN 7, 8, 9 Power Recline with Integrated Shear Reduction (ISR) (E004) $5,580 SAPTPRN 7, 8, 9 CG Power Tilt and Power Recline with Integrated Shear Reduction (ISR) (E007) $8,785 SAPES 7, 0 " Power Elevating Seat Module for transfer assist (E2300) $4,75 ADDPES 0 Module - Add an " Power Elevating Seat to either SAPTN, SAPRN or SAPTPRN (E2300) $2,995 ADDMR 8, 9 Module - Manual Recline with Integrated Shear Reduction (E22) $,280 Note 7 These options include the fully adjustable Amyseat (SAABA). Note 8 It is recommended to use the Contour Back Support option with the power or manual reclines (SB or SB/) Note 9 These options are not available with the Pediatric Seat Frame Notice for Pride Q-Logic Electronics: Reduced speed requires going through drive controls Note 0 Please select one of these part numbers for reduced speed: SWTJSS, SWTJSD or SWTJSM ELECTRONICS - SINGLE OR DUAL ( OR 2 ACTUATORS) POWER SEAT FUNCTION CONTROLLERS SAC Single ( Actuator) Power Seat Function Controller to Interface through the Wheelchair Electronics (E230) $,085 DAC Dual (2 Actuators) Power Seat Function Controller to Interface through the Wheelchair Electronics (E23) $,30 With the SAC or DAC, please select one activation and position from the list below SWTOGGLE or 2 Single Toggle Switch (Single Mode: DAC - Dual Mode: SAC) User Activation Attendant Activation SWPUSH Single Push Button Switch (Single Mode: SAC) User Activation Attendant Activation SWPUSH2 or 2 Dual Push Button Switch (Single Mode: DAC - Dual Mode: SAC) User Activation Attendant Activation SWTJSS Single actuator activation through the Joystick or Specialty Controls SWTJSD 2 Dual actuator activation through the Joystick or Specialty Controls SWTVR2 3 Tilt only activation through -key PG Drives VR2 Joysticks SWTMK-ACCT 4 Tilt only activation through Invacare: SPJ-ACC SPJ-PSS 5 MPJ Note Note 2 Note 3 Note 4 Note 5 Note Requires the Single Actuator Controller (SAC) Requires the Dual Actuator Controller (DAC) Requires the P&G -Key VR2 Joystick from Amysystems, Quickie or Pride. Requires the SPJ-ACC, SPJ-PSS or MPJ Joystick with the MK90-ACC controller from Invacare. Requires the use of a Single Switch with a /8" phono plug (Mono) Requires the use of a Single or a Dual Switch with a /8" phono plug ELECTRONICS - MULTIPLE (3 to ACTUATORS) POWER SEAT FUNCTION CONTROLLER MAC Multiple (3 to Actuators) Power Seat Function Controller to Interface through the Wheelchair Electronics (E23) $2,300 With the MAC, please select one activation and position from the list below 4-Way Toggle Switch (Up to 4 Activations) - User Activation Attendant Activation SWMULTI 7 Triple Toggle Switch (Up to 5 Activations) - User Activation Attendant Activation SWMULTIT 7 4-Way Push Button Switch - User Activation Attendant Activation 5-Way Push Button Switch - User Activation Attendant Activation SWPUSH4 7 SWPUSH5 7 SWTJSM 7 Multiple Actuator activation through the Joystick or Specialty Controls Note 7 Requires the Multiple (3 to Actuators) Power Seat Function Controller (MAC) SWITCH ACTIVATION HAND MOUNT Switch Installation: TSML (Install Switch on LH side) TSMR (Install Switch on RH side) JOYSTICK MOUNT SOSWJSM Swing Away Joystick Mount - Height adjustable, Angle adjustable and Multi-Axis (E028) $244 Set-up with standard installation to swing-away sideways Set-up at 35 to swing-away sideways and downwards JSMFH Fixed joystick mount support JOYSTICK SUPPORT MOUNT JOYSTICK HAND MOUNT Install Joystick on Right hand side HML Install Joystick on Left hand side HMR

3 Specifications are subject to change without notice. 204, Amylior Inc. (November 204) AMYSEAT - USA (Rev. ) Page 3 of PRE-SET SEAT ANGLE (For Non-Reclining Backs) SOBAA Please Select one: PEDIATRIC ADJUSTABLE SEAT WIDTH RANGE BETWEEN " AND " SOWN- (Seat to Floor Height increases by ¼") " (SOWN) 4" (SOWN4) 2" (SOWN2) 5" (SOWN5) 3" (SOWN3) " (SOWN) PEDIATRIC ADJUSTABLE SEAT DEPTH RANGE BETWEEN " AND " " (SODN) 4" (SODN4) 2" (SODN2) 5" (SODN5) 3" (SODN3) " (SODN) STANDARD ADJUSTABLE SEAT WIDTH RANGE BETWEEN 5" AND 20" SOWN (Width adjustment from 5" to 20" with a maximum Depth of 9" ) SOWN (Width adjustment from 5" to 20" with a maximum Depth of 22" ) 5" (SOWN5) " (SOWN) 7" (SOWN7) 8" (SOWN8) 9" (SOWN9S) 20" (SOWN20S) LARGE ADJUSTABLE SEAT WIDTH RANGE BETWEEN 9" AND 24" SOWN (Width adjustment from 9" to 24" and Depth range of 8" to 22" ) 9" (SOWN9L) 22" (SOWN22) 20" (SOWN20L) 23" (SOWN23) 2" (SOWN2) 24" (SOWN24) SEAT WIDTH 25" SOWCUS Custom Seat Width. Specify: " $45 ADJUSTABLE SEAT DEPTH RANGE BETWEEN 5" AND 22" 5" (SODN5) 9" (SODN9) " (SODN) 20" (SODN20) 7" (SODN7) 2" (SODN2) 8" (SODN8) 22" (SODN22) SEAT DEPTH 23" SODCUS Custom Seat Depth. Specify: " $250 BACK CANE HEIGHT 8 (The back cane height measurement is taken from the seat pan to the top of the push handles) " (SOBCH) 20" (SOBCH20) 8" (SOBCH8) 8 22" (SOBCH22) 24" (SOBCH24) 2" (SOBCH2) Note 8 22" is the minimum back cane height required with a power or manual recline. BACK CANE HEIGHT 27" SOBHCUS Custom Back Cane Height. Specify: " $250 BACK SUPPORT SB 9 Contour back support " to 24" Wide with a maximum back shell height of 22" SBO Omission of the Contour Back Support (CREDIT) -$00 SB/ 9 Contour Back Support for Non-Standard Sizes Specify Width: " Height: " $295 Note 9 It is recommended to use the Contour Back Support option with the power or manual reclines (SAPRN, SAPTPRN and ADDMR) 2 BACK SUPPORT TOTAL HEIGHT (MEASURED FROM THE SEAT PAN TO THE TOP OF THE BACK) " (SOBH) 20" (SOBH20) 8" (SOBH8) 20 22" (SOBH22) 24" (SOBH24) 2" (SOBH2) 28" (SOBH28) Note 20 With a power or manual recline, the minimum height is 22". Note 2 The space between the bottom of the back and the seat pan is 4" with a non-reclining back and " with a reclining back

4 Specifications are subject to change without notice. 204, Amylior Inc. (November 204) AMYSEAT - USA (Rev. ) Page 4 of ARMRESTS CANTILEVER - HEIGHT ADJUSTABLE (For Non-Reclining Backs - Choose 2) SOAFBPFLH SOAFBPFRH SOAFBPDLH SOAFBPDRH SOAFBFLH SOAFBFRH SOAFBDLH SOAFBDRH Pediatric Flip-Back Cantilever - Full Length Left Side (Height Adjustable from 7" to 5" in " increments) Pediatric Flip-Back Cantilever - Full Length Right Side (Height Adjustable from 7" to 5" in " increments) Pediatric Flip-Back Cantilever - Desk Length Left Side (Height Adjustable from 7" to 5" in " increments) Pediatric Flip-Back Cantilever - Desk Length Right Side (Height Adjustable from 7" to 5" in " increments) Adult Flip-Back Cantilever - Full Length Left Side (Height Adjustable from 7" to 5" in " increments) Adult Flip-Back Cantilever - Full Length Right Side (Height Adjustable from 7" to 5" in " increments) Adult Flip-Back Cantilever - Desk Length Left Side (Height Adjustable from 7" to 5" in " increments) Adult Flip-Back Cantilever - Desk Length Right Side (Height Adjustable from 7" to 5" in " increments) DUAL POST - HEIGHT ADJUSTABLE (For Non-Reclining Backs - Choose 2) SOADPPLH Pediatric Adjustable Height Dual Post - Left Side (Height Adjustable from 7" - 0") (E0973) SOADPPRH Pediatric Adjustable Height Dual Post - Right Side (Height Adjustable from 7" - 0") (E0973) SOADPFLH Adult Adjustable Height Dual Post - Full Length Left Side (Height Adjustable from 9 ½" - 3 ½") (E0973) SOADPFRH Adult Adjustable Height Dual Post - Full Length Right Side (Height Adjustable from 9 ½" - 3 ½") (E0973) SOADPDLH Adult Adjustable Height Dual Post - Desk Length Left Side (Height Adjustable from 9 ½" - 3 ½") (E0973) SOADPDRH Adult Adjustable Height Dual Post - Desk Length Right Side (Height Adjustable from 9 ½" - 3 ½") (E0973) RECLINING FLIP-UP, HEIGHT ADJUSTABLE (For Reclining Backs - Choose 2) SOANIFLH Adult Reclining armrest - Full Length Left Side (Height Adjustable from 0 ½" to 4" in ½" increments) SOANIFRH Adult Reclining armrest - Full Length Right Side (Height Adjustable from 0 ½" to 4" in ½" increments) SOANIDLH Adult Reclining armrest - Desk Length Left Side (Height Adjustable from 0 ½" to 4" in ½" increments) SOANIDRH Adult Reclining armrest - Desk Length Right Side (Height Adjustable from 0 ½" to 4" in ½" increments) ARMREST HEIGHT ADJUSTMENT AT FACTORY Please set the Armrest Height at: " (The Armrest Height is taken from the seat pan to the top of the armpad. Not required for Dual Post) ARMPADS Full Length Hybrid Gel and Foam armpad (4" x 2.5") - Select Side: Left Hand Side Right Hand Side Desk Length Waterfall (0") - Select Side: Left Hand Side Right Hand Side Full Length Waterfall (4") - Select Side: Left Hand Side Right Hand Side SOGELF $0 SOWAPD $25 SOWAPF $25 SOFAPD Desk Length Standard (0") - Select Side: Left Hand Side Right Hand Side SOFAPF Full Length Standard (4") - Select Side: Left Hand Side Right Hand Side Arm Trough with Hand Support (8" x 4 ½") (E2209) - Select Side: Left Hand Side Right Hand Side SOCAR 22 $28 Note 22 Arm Trough Armpads may interfere with Armrests Flipping back. FOOTRESTS SOPAAF 28 Pediatric Swing-Away Footrests Set at: 0 70 Select Footrest Range: SOFLP5 (5 ½" - 7 ½") SOFLP8 (8 ½" - 0 ½") SOFLP0 (0 ½" - 5 ½") SOSAAF 27, 28 Adult Swing-Away Footrests Set at: 0 70 Select Footrest Range: SOFLA0 (0 ½" - 5 ½") SOFLA4 (4 ½" - 9 ½") SOAAF 27, 28 Adult Heavy-Duty Swing-Away footrests Set at: 0 70 Select Footrest Range: SOFLHD2 (2 ½" - 5 ½") SOFLHD4 (4 ½" - 9 ½") $395 ADDPL 24, 27, Adult Power Elevating & Articulating Legrests (E00) Please Select Function: Individual 25 Combined 2 $2,045 Select Footrest Range: SOFLPW2 (2 ½" - 5 ½") SOFLPW4 (4 ½" - 9 ½") Please set the Footrest Length at: " (The footrest length is taken from the seat pan to the heel) Note 23 Depending on the seat configuration, this option may not be available. Note 24 This option includes calf pads Note 25 Individual legs count as two power functions. Note 2 Combined legs count as one power function. Note 27 This option is not available with the pediatric seat frame (SOWN-) Note 28 The Footrest Length is taken from the top of the seat pan to the top of the footplate. FOOTPLATES & ACCESSORIES SOSFAF Flip-up Footplates SOAFP Angle Adjustable & Flip-up Footplates - Each (K0040) $85 SOAHL Heel Loops - Each (E095) $2 SOACPFR Calf Pads for Adult Heavy-Duty Swing-Away footrests (SOAAF) with adjustable hardware - Each (E0995) $38

5 Specifications are subject to change without notice. 204, Amylior Inc. (November 204) AMYSEAT - USA (Rev. ) Page 5 of CENTER MOUNTS SOAAF90 3, 32, 34 ADDPF 29, 30, 3, 32, 33, Fixed Center Mount Interface Bracket Select Foot Platform Range: SOFBP7 (7 ½" - 2 ½") SOFBA2 (2 ½" - ½") SOFBA ( ½" - 20 ½") 90 Power Center Mount Elevating & Articulating Foot Platform (K008) SOFBPW2 (2 ½"- ½") SOFBPW ( ½"- 20 ½") Please set the Footrest Length at: " (The footrest length is taken from the seat pan to the heel) $2,045 Note 29 The power center mount counts as one power function. Note 30 This option includes calf pads Note 3 Links and attaches the one piece center mount foot platform (SOFUFP) or the split footplates (SOAFPFB) to the seat Note 32 Please Select the one piece center mount foot platform (SOFUFP) or the split footplates (SOAFPFB) Note 33 This option is not available with the pediatric seat frame (SOWN-) Note 34 The Foot Platform Length is taken from the top of the seat pan to the top of the foot platform or split foot plates. FOOT PLATFORMS & ACCESSORIES SOFUFP Flip-up one piece Foot Platform SOAFPFB Angle Adjustable & Flip-up Split Footplates for center mount - Each (K0040) $85 SOACPCM 35 Calf Pads for 90 Fixed Center Mount (SOAAF90) with adjustable hardware - Each (E0995) $38 Note 35 Not available with the pediatric length (SOFBP7-7 ½" - 2 ½") SEAT POSITIONING SOAUTO 55" Seat Positioning Strap SOAUTO80 80" Seat Positioning Strap $75 HEADREST SONUAHR SOFHRS Using headrest mounting hardware other than SOSAH or SOMAH located below. Specify: Small Curved Headrest Pad 4" x 9" (E0955) $233 SOFHRM Medium Curved Headrest Pad 5" x 0" (E0955) $233 SOFHRL Large Curved Headrest Pad " x " (E0955) $233 SOMAH Multi-axis Removable Mounting Hardware (E028) $238 SOHRBC Bracket to Mount on the Contour Back Support (Without Recline) SOHRSB Bracket to Mount on the Seat Frame Crossbar (Without Recline) SOHRPR Bracket to Mount on the Seat Frame (For Reclining Backs, but excludes the Corbeau Back) * Please select one of the headrest options with the mounting hardware and specify where the headrest will be installed (The frame or back cushion) LATERAL TRUNK SUPPORTS SOSLS3 Adjustable Laterals with Small Curved Pads (Each) - 3" x 5" (E095) SOSLM4 Adjustable Laterals with Medium Curved Pads (Each) - 4" x " (E095) SOSLL5 Adjustable Laterals with Large Curved Pads (Each) - 5" x 7" (E095) SOSLHM Adjustable Swing-Away Hardware Mounts - Each (E028) $238 ** Please select one of the lateral pads and the adjustable & removable hardware. HIP & THIGH SUPPORTS SOHTSS0 Adjustable Hip & Thigh Support Pads (Each) - Small 0" x 4" (E095) SOHTSM2 Adjustable Hip & Thigh Support Pads (Each) - Medium 2" x 5" (E095) SOHTSL4 Adjustable Hip & Thigh Support Pads (Each) - Large 4" x " (E095) SOHTSARH Adjustable and Removable Hip & Thigh Support Hardware - Each (E028) $238 *** Please select one of the hip & thigh support pads and the adjustable & removable hardware. ACCESSORIES SOCH Cup Holder (Self-Leveling) $90 SOCPH Ram Mounts X-Grip Cell Phone Holder SOTHS Ram Mounts X-Grip Small Tablet Holder $70 SOTHL Ram Mounts X-Grip Large Tablet Holder with Swivel $270

6 3 SECTION Lead times will increase depending on the custom order pipeline at the time we receive the wheelchair base. Note 3 Please call for Quote and specifications for these options. O2 Holder SUPOXY 37 Custom Non-Articulating Oxygen Tank Holder (E2208) SUPOXYA 38 Custom Articulating Oxygen Tank Holder (K008) MRH (Mount on Right) MRH (Mount on Right) MLH (Mount on Left) MLH (Mount on Left) $270 $,95 D-Size Oxygen Tank (* 22" Tall x 4.3" Diameter) * The height includes the valve E-Size Oxygen Tank (* 3" Tall x 4.3" Diameter) * The height includes the valve Note 37 Not available with a power tilt and/or power recline Note 38 Required with a power tilt and/or power recline VENT TRAY (Please complete in Full) SOVENT SOVTBE 39 Custom Vent Tray Articulating Vent Box (Required with Power Tilt and/or Recline) (E030) Model: $,420 Fixed Vent Box (E029) Model: Custom Tray for the Ventilator Battery (K008) $400 $495 Battery Container Dimensions for: Width: " Depth: " Height: " U Note 39 22NF GR24 GR34 Amysystems does not supply the battery, charger or the wiring for the Vent. These items are normally provided by the Vent Manufacturer. OTHER OPTIONS (Request For Quote) PAT Power Anterior Tilt 40 Four (4) - Point wheelchair Tie-Downs Power 5 Lateral Tilt Raise the Left Side onlyv Power Elevating Stretcher (Please call CSR for availability with configuration and user weight capacity) Power Power Flip-up Foot Platform (Please call CSR for availability with configuration and user weight capacity) Power Vertical Lifting Foot Platform (Please call CSR for availability with configuration and user weight capacity) # Other custom options. Specify in notes section bellow. # 2 Other custom options. Specify in notes section bellow. # 3 Other custom options. Specify in notes section bellow. Raise the Right Side only Raise the Left & Right Side 4-Point wheelchair transport brackets are not crash-tested in accordance with WC-9 Note 40 Use these transport brackets only to secure an unoccupied wheelchair during transport. Note Please specify details and specifications for these options. SEAT TO FLOOR HEIGHT SPECIFICATION (If not standard) SOMHSS Specific seat to floor height requirement other than standard. Custom upcharges may apply. Required at: " (± ¼" Range) NOTES / SPECIAL REQUESTS / SPECIFICATIONS SAVE RESET PRINT FORM / info@amysystems.com / Phone: (888) / Fax: (877) Specifications are subject to change without notice. 204, Amylior Inc. (November 204) AMYSEAT - USA (Rev. ) Page of