M300 Corpus HD. Dealer Information. Client Information. Client Measurements

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1 Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Address: Client Information Permobil recommends that the client is evaluated by a certified rehab specialist. * First Name: * Last Name: Diagnosis: Funding Source: Client Age: Client Measurements * Weight: *Height: A) Top of Shoulders: B) Chest Depth: C) Chest Width: D) Seat Depth: E) Top of Head: F) Elbow to Hand: G) Seat Pan to Elbow: H) Hip Width: *I) Knee to Foot: Display s on order/quote: Three column pricing on order/quote: Please send order/quote to fax#: (800) to: sales@permobil.com Permobil Ltd Mary St. Aurora, Ontario L4G 1G3 Tel: (888) CAN Fax: (905) US Fax: (800) Canadian prices effective January 14, 2013 and payable in Canadian dollars.

2 Chair Model and Colors I10908 M300 Base Corpus HD - SPO 9, Price Includes: M300 Power HD Base Set Up For One Power Seat Function, Shock Absorbing Suspension System, R-net Controller, Tie-Down Hardware For Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below. 5.0mph, Weight Capacity = 450 lbs. I M300 Base Corpus HD - MPO 9, Price Includes: M300 HD Power Base Set Up For Multiple Power Seat Functions, Shock Absorbing Suspension System, R-net Controller, Tie-Down Hardware For Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below. 5.0 mph, Weight Capacity = 450 lbs. CHOOSE DRIVE TIRES: I Tri-Spoke Split Rim w/ Flat Free Drive Tire 3x8" I Tri-Spoke Split Rim w/ Pneumatic Tires - 3x8" OPTIONAL DRIVE TIRES: I10782 Tri-Spoke Split Rim w/ Snow Tire Pneumatic 3x8" Snow tires are designed for use in cold weather conditions. The nylon compound in these tires remains flexible at low temperatures, but wears more easily. Therefore, the snow tires (sold as wheel assemblies) are not recommended for year-long use and must be ordered along with standard drive wheels. CHOOSE SHROUD COLOR: I M300 HD Shroud - Onyx Black I M300 HD Shroud - Volcano Red I M300 HD Shroud - Sublime Green I M300 HD Shroud - Platinum Silver I M300 HD Shroud - Cobalt Blue I M300 HD Shroud - Purple Rain I M300 HD Shroud - Phantom Gray I M300 HD Shroud - Pop Star Pink I M300 Shroud - Digital Army Camo (UCP) Hydrographic processing used to apply design. Includes no-gloss clear coat. I M300 Shroud - MultiCam Camo Hydrographic processing used to apply design. Includes no-gloss clear coat. I M300 Shroud - Realtree AP Camo Hydrographic processing used to apply design. Includes no-gloss clear coat. ADP $9, Code ADP $ Code CHOOSE HUBCAP COLOR: Match Hubcap Color to Shroud: Note: Hub caps will be matched to shroud color/decoration if no selection is made. Matched I10871 hub caps carry the prices listed below. Solid Color Hub Cap - Pair Platinum Silver: Onyx Black: Cobalt Blue: Phantom Gray: Pop Star Pink: Volcano Red: Purple Rain: Titan Blue: Sublime Green: Crystal Blue: Vintage Wine: Extreme Yellow: I10872 Chili Pepper Red: Green Metallic: Decorated Hub Caps - Pair Digital Army Camo: MultiCam Camo: RealTree AP Camo: Base Options MUST CHOOSE FIXED SEAT TUBE: Page 2 of 16

3 Base Options MUST CHOOSE FIXED SEAT TUBE: I HD Seat Tube Fixed MUST CHOOSE BATTERIES: IM24 SLD G FT Batteries, Grp 24 (72Ah) Sealed LA/Gel, Installed IM34 SLDG Batteries, Grp 34 (60Ah) Sealed LA/Gel, Installed CHOOSE SEAT PAN TO FLOOR HEIGHT: I Set Seat to Floor Height at 18" I Set Seat to Floor Height at 19" I Set Seat to Floor Height at 20" I Enhanced Steering Perform Unit (ESP), R-net 1, Recommended item with switched drive inputs for improved tracking. I LED Light Kit for M300 / M400 w/ R-net Electronics I10715 Compact Laptop Ventilator Tray - Corpus 3G Seat 1, Mounts to rear of Corpus 3G backrest hinge. Accommodates Pulmonetic Systems / CareFusion LTV Series and similar sized Laptop Ventilators. The tray is 330mm Tall, adjustable Width between 200mm - 330mm, and adjustable Depth between 50mm - 165mm. I10787 Overall backrest angle limited to 150 when mounting this ventilator tray. Custom Option. Battery Tray for Laptop Ventilator Tray Mounts to rear of Laptop Ventilator Tray. Measures 290mm W x 170mm H x 42mm D. Accomodates Pulmonetic Systems Lithium-Ion Battery Pack, CareFusion SprintPack Battery I10788 System, or Richardson PowerTech Vent Power Center. Custom Option. O2 Holder for Laptop Ventilator Tray Mounts to Left or Right Side of Laptop Vent Tray. O2 Holder is 175mm Tall. Width infinitely adjustable 90mm - 170mm. Depth infinitely adjustable 95mm - 125mm. Custom Option. ID51113 Programming Key for R-net - Permobil Version Joystick Options CHOOSE JOYSTICK TYPE: PLEASE NOTE: For all remote joystick modules shown below, you must also select an expandable controller. For additional input devices, refer to Alterative Drive Systems Section. I R-net LED Remote Joystick Module ID51185 R-net Remote Colour JS w/ Mono Jacks, No Lights 1, ID51188 R-net Remote Colour JS w/ Toggle Switches, No Lghts 1, ID51153 R-net Remote Colour JS w/ Mono Jacks, Lights 1, ID51149 R-net Remote Colour JS w/ Toggle Switches, Lights 1, ID51190 R-net Remote Colour JS w/ Spd Pot/Toggle, Lights 1, I R-net Remote Color JS w/ Lights, Heavy Duty Gimble 1, Heavy-Duty modification enables gimble to hold up to extreme operating forces. Reinforced housing is attached to a standard Color LCD R-net Joystick. 3" long joystick knob has 3/4" I diameter. Not compatible with alternative joystick handles. Compact Advanced Joystick for R-net 1, Compact sized joystick that does not contain an LCD Display. Contains two mono jacks for mode & on/off. Does NOT contain a wrist support pad. If you want a wrist support pad, please select I10621, below. I10621 Add Wrist Pad to Compact Joystick Advanced CHOOSE JOYSTICK HANDLE TYPE: ADP $ Code ADP $1, Code WEX1 WEX1 WEX1 Page 3 of 16

4 Joystick Options CHOOSE JOYSTICK HANDLE TYPE: I10045 Cone Shaped Joystick Knob - Standard I Chin Cup For Joystick Knob I "T" Handle For Joystick Knob I "Large Ball" For Joystick Knob I "Softball" For Joystick Knob I "Mushroom" For Joystick Knob I "Stick" For Joystick Knob I " Black Foam Ball For Joystick Knob IPC101B Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft IPC102B Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft IPC107B Bodypoint J/S Handle Dome Shaped, Rubber I10664 Joystick Mount Right - Fixed I10665 Joystick Mount Left - Fixed I Retractable Joystick Mnt Right - R-net, VR I Retractable Joystick Mnt Left - R-net, VR I Mount Standard Joystick on Corpus 3G Back Hinge Standard R-net Joystick is mounted to backrest hinge. Can be chosen instead of PN I Mount on Left: Mount on Right: I Midline Control Mount - Pilot+ & R-net Mount Midline on Left Armrest: Mount Midline on Right Armrest: I10793 Stealth Gatlin Mid Line Mount - 8 Position Features eight locking positions each 45 apart. Adjustments are made by pulling out on mounting arm and rotating to desired angle. Joystick bracket sold separately. Please indicate if you want it mounted on left or right armrest: Mount Midline on Left Armrest: Mount Midline on Right Armrest: I10794 Stealth Gatlin Mid Line Mount - 2 Position Designed for easy swing away. Mount can be set to swing from horizontal to 95 or from horizontal to 180. Joystick bracket sold separately. Please indicate if you want it mounted on left or right armrest: Mount Midline on Left Armrest: Mount Midline on Right Armrest: I10803 Stealth Gatlin Bracket for Std & Compact JS Adv I10804 Stealth Gatlin Bracket for Compact Joystick I10805 Stealth Gatlin Bracket for Mini Joystick I10806 Stealth Gatlin Swivel Bracket for Omni I10842 PermoFix Joint for Gatlin ( a) Includes a shim that allows the PERMOFix Joint to be mounted on the 1/2" Stealth Gatlin arm. Provides an adjustable mount for a Mini Joystick or Compact Joystick. I10802 Stealth Height Adjustable Mnt (ARM250-P) Replaces standard UT panel bracket. Provides 1.75" of height adjustability to all Permobil joystick mounts and Stealth Gatlin Mid Line mounts. WEPM WEPM WE3D WE3D WE3D I10411 Expandable Controller - R-net Must be ordered with the expandable/remote joysticks (PN: I10410, I , ID51040, ID51108, ID51042, and I ). I10513 Harness for Expandable Controller Must be ordered with any Expandable Controller (I10411 or I10450) I Co-Pilot Attendant Control R-net - Corpus 3G 4, I Attendant Control R-net - Corpus 3G 1, I R-net BT Mouse Module Page 4 of 16 ADP $ Code

5 Joystick Options I10582 Output Module (IOM) for R-net Control System 1, This allows a user to control an external device (ex: Communication Device, ECU, Door Opener, etc.) through the drive input (JSM, Head Array, etc.). One output module is required for each separate external device to be controlled. Up to three output modules can be installed on one wheelchair. Seating System CHOOSE SEATING SYSTEM: PLEASE NOTE: Weight Limit 450lbs. For the Corpus HD Seat on the M300, there is a half speed drive limit when the Total Backrest Angle (TBA) > 135 and a drive inhibit at 150 of TBA. There is also a drive inhibit at 20 of tilt. I10910 HD Seat w/ No Tilt & Manual Recline 7, I10911 HD Seat w/ No Tilt & 150 Power Recline 8, I10912 HD Seat w/ 45 DuraCore Tilt & Manual Recline 7, I10913 HD Seat w/ 45 DuraCore Tilt & 150 Power Recline 12, Seating System Options CHOOSE SEAT FUNCTION CONTROL TYPE: I10418 Single Seat Function Control Switch for R-net Please choose either Push Buttons or Toggle Switches below. I10419 Single Seat Function Control Kit for R-net 1, For operation of a single seat function through the wheelchair electronics via the drive control and/or ICS Switchbox. Order with R-net Controller or remote joystick options. Please I10585 indicate below if you want push buttons or toggles on the ICS Switchbox. Multiple Seat Function Control Kit for R-net 2, MUST be selected if ordering two or more seat functions. This device is used to operate two or more seat functions through the wheelchair electronics via the drive control and/or ICS switch box. Order with R-net electronics or remote joystick options. Please indicate below if you want push buttons or toggles on the ICS Switchbox. CHOOSE PUSH BUTTONS OR TOGGLES: I Push Buttons on Seat Function Control Kit I Toggle Switches on Seat Function Control Kit I Do Not Install ICS Switchbox, Send as Part CHOOSE MOUNTING POSITION OF ICS SWITCHBOX: I10626 Mount ICS Switchbox onto R-net Joystick Bracket ICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item I is selected, the ICS Switchbox will swing away with the Joystick Module. Mount ICS Switchbox onto Armrest I Mount on Left: Mount on Right: Mount ICS Switchbox on Backrest Mount on Left: Mount on Right: I ICS Alternative Switchbox for R-net Electronics 1, Not available with VR2 Electronics. Seat function interface box which accommodates up to 8 momentary switches. Provides an additional method to accessing the seat functions. You must still order the Multiple Seat Function Control Kit if ordering this part. 1/8" mini-mono switches not included. ADP $1, Code SEC1P1005 ADP $1, Code Page 5 of 16

6 Seating System Options I Remote Stop System - All Electronics 1, Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on the wheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be used together. Custom charge may be required if ordering with a low backrest height or a pediatric wheelchair. If ordering Remote Stop System with a K450, push handles must also be selected. I10750 Memory Seat Program, Corpus 3G w R-net I10888 Legrest Movement Linked to Recline Electronically Power Legrest will raise when Power Recline moves backward and will lower when back moves forward. If Power Legrest is operated, Power Recline will NOT automatically reposition. Feature works through ICS Switchbox and Driver Control. I10898 Enable Independent Repositioning Mode Enables the Corpus 3G Independent Repositioning Mode through all Driver Control Input Devices. If a Switchbox Layout with memory is chosen, IRM will be accessible through the ICS Switchbox. Backrest Options CHOOSE FIXED OR SLIDING BACKREST KIT: I Sliding Backrest Kit - 5" Mechanical Shear I Fixed Backrest Kit - No Mechanical Shear CHOOSE BACKREST TYPE: BACKREST HEIGHT NOTE: Backrest heights are measured from the seat pan to the top of the backrest shell with the backrest set at 90. I Corpus HD Ergo Backrest - 20"W x 21"T (C3GERGBCA) I Corpus HD Ergo Backrest - 22"W x 21"T I Corpus HD Ergo Backrest - 24"W x 21"T I10915 Solid Back 20"W x 21"T - Corpus HD Seat I10916 Solid Back 22"W x 21"T - Corpus HD Seat I10917 Solid Back 24"W x 21"T - Corpus HD Seat PLEASE NOTE: All taller backrests listed below include: lumbar pad, a UT rail mounted at the top for lateral adjustment of the headrest, and split backrest feature with height adjustment in 1" increments. Please indicate below where you want the height set at so that a properly sized backrest cushion can be provided. I Corpus HD Ergo Back -20"W x 24-29"T (C3GERGBCA) I Corpus HD Ergo Back -22"W x 24-29"T I Corpus HD Ergo Back -24"W x 24-29"T I10919 Solid Back 20"W x 24-29"T - Corpus HD Seat I10920 Solid Back 22"W x 24-29"T - Corpus HD Seat I10921 Solid Back 24"W x 24-29"T - Corpus HD Seat Set Backrest at 24" Set Backrest at 25" Set Backrest at 26" Set Backrest at 27" Set Backrest at 28" Set Backrest at 29" ADP $1, Code CHOOSE BACKREST CUSHION: I10659 Leatherette Cushion - Corpus 3G Ergo Back Page 6 of 16

7 Backrest Options CHOOSE BACKREST CUSHION: I10660 Black Mesh Cushion - Corpus 3G Ergo Back I Omit Backrest Cushion I10725 Split Backrest Cushion - Corpus 3G Custom Option. Seat Sizing CHOOSE SEAT WIDTH SETTING: I Set Seat Width at 19" I Set Seat Width at 21" I Set Seat Width at 23" I Set Seat Width at 25" CHOOSE SEAT DEPTH: PLEASE NOTE: Odd numbered seat depths can be made 1" shorter without any additional parts. For example, a 21"D seat can also be set at 20"D. I Corpus HD Seat Depth 19" I Corpus HD Seat Depth 20" I Corpus HD Seat Depth 21" I Corpus HD Seat Depth 22" I Corpus HD Seat Depth 23" I Corpus HD Seat Depth 24" I Corpus HD Seat Depth 25" CHOOSE SEAT CUSHION: I10651 Corpus 3G Ergo Seat Cush - Leatherette (C3GERGSCA) I10652 Corpus 3G Ergo Seat Cush - Black Mesh (C3GERGSCA) I Omit Seat Cushion Armrest Options CHOOSE ARMBAR MOUNTING POSITION: I Set Armbar at 20"W Between Armrests: I Set Armbar at 21"W Between Armrests: I Set Armbar at 22"W Between Armrests: I Set Armbar at 23"W Between Armrests: I Set Armbar at 24"W Between Armrests: I Set Armbar at 25"W Between Armrests: CHOOSE ARMREST HEIGHT MOUNTING POSITION: I10923 Height Adjustable Amrests I10924 Height Adjustable Amrests - NC SET ARMREST HEIGHT AT: Corpus HD Armrests are infinitely adjustable from 8" - 16", measured from the seat pan to the top of the arrmrest pad. No additional parts are needed to get this full range of adjustment. In one inch increments (ex: 8", 9", etc.), please indicate where you would like the armrests set. $46.00 ADP $ Code ADP $ Code ADP $ Code Page 7 of 16

8 Armrest Options CHOOSE ARMREST PAD RIGHT: I "x13" Corpus 3G Armrest Pad Right - Leatherette I "x16" Corpus HD Armrest Pad Right - Leatherette I "x18" Corpus HD Armrest Pad Right - Leatherette I "x13" Corpus HD Armrest Pad Right - Black Fabric I "x16" Corpus HD Armrest Pad Right - Black Fabric I "x18" Corpus HD Armrest Pad Right - Black Fabric I "x13" Corpus HD Arm w/ Stealth Gel Pad - Right I "x16" Corpus HD Arm w/ Stealth Gel Pad - Right CHOOSE ARMREST PAD LEFT: I "x13" Corpus 3G Armrest Pad Left - Leatherette I "x16" Corpus HD Armrest Pad Left - Leatherette I "x18" Corpus HD Armrest Pad Left - Leatherette I "x13" Corpus HD Armrest Pad Left - Black Fabric I "x16" Corpus HD Armrest Pad Left - Black Fabric I "x18" Corpus HD Armrest Pad Left - Black Fabric I "x13" Corpus HD Arm w/ Stealth Gel Pad - Left I "x16" Corpus HD Arm w/ Stealth Gel Pad - Left I Corpus 3G Arm Trough Adapter 1" - Pair For aftermarket armrest pads. Please indicate below if they should be installed or on chair I sent as parts. Corpus 3G Arm Trough Adpater 7/8" - Pair For aftermarket armrest pads. Please indicate below if they should be installed or on chair sent as parts. Install Arm Trough Adapters: Send Arm Trough Adapters as Parts: I Armrest Pouch-Right I Armrest Pouch-Left I10705 Corpus 3G Armrest Side Support - Right Outer Custom Option. Leatherette Pad (2"T x 8.5"L). I10706 Corpus 3G Armrest Side Support - Left Outer Custom Option. Leatherette Pad (2"T x 8.5"L). I10707 Corpus 3G Armrest Side Support - Right Inner Custom Option. Leatherette Pad (2"T x 8.5"L). Recommend 2" wider width between the I10708 armrest to ensure armrests will flip-up. Corpus 3G Armrest Side Support - Left Inner Custom Option. Leatherette Pad (2"T x 8.5"L). Recommend 2" wider width between the armrest to ensure armrests will flip-up. I10937 Stealth Elbow Support HD w/ 3" x 10" Pad - Right I10938 Stealth Elbow Support HD w/ 3" x 10" Pad - Left I10881 Adjustable Elbow Support Hardware - Right I10882 Adjustable Elbow Support Hardware - Left Legrest Options CHOOSE LEGREST TYPE: I Corpus HD Manual Adj Legrest Elevation ADP $ Code Page 8 of 16

9 Legrest Options CHOOSE LEGREST TYPE: ADP $3, Code I Power Elevating Center Mount Legrests , Includes mechanical articulation. CHOOSE FOOTPLATE STYLE: I pc Wide Corpus HD Footplates - 9"D x 7.5"W I pc Extra Wide Corpus HD Footplates - 9"D x 9"W FOOTPLATE HEIGHT POSITION: SET FOOTPLATE HEIGHT AT: This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrest assembly is at 90 DO NOT INCLUDE CUSHION THICKNESS IN YOUR MEASUREMENT. In one inch increments, please indicate desired footplate height. NOTE: Standard Corpus HD footplate height range is 6" - 18". Calf Pads are not available at heights less than 10". CHOOSE LATERAL FOOTPLATE ROTATION OPTIONS: I Lateral Footplate Rotation - Fixed I Lateral Footplate Rotation - Enabled I UT Calf Support Kit (A) w Mesh Cover & Adj Hardware 5.5"W x 6"T Pad. Compatible with footplate heights of 10" - 18". I UT Calf Support Kit (H) w Mesh Cover & Adj Hardware "W x 7"T Curved Pad. Compatible with footplate heights of 11" - 18". I UT Calf Support Kit (D) w Mesh Cover & Adj Hardware "W x 8"T Pad. Compatible with footplate heights of 12" - 18". I10933 Stealth Gel Pads - Wide Footplates (Pair) I10934 Stealth Gel Pads - Extra Wide Footplates (Pair) Accessories MUST CHOOSE POSITIONING BELT: I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium I10404 Bodypoint Padded Hip Belt UniTrack - Medium I10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large I10408 Bodypoint Padded Hip Belt UniTrack - Large I10935 Bodypoint Padded Hip Belt UniTrack - Extra Large I Positioning Belt Retractable I Positioning Belt Retractable Long I Headrest Corpus 3G Back, 10"W x 5"T, Leatherette Must also select PN I I Headrest Corpus 3G Back, 10"W x 5"T, Black Fabric Must also select PN I I Headrest Corpus 3G Back, Ergo Shape, Black Fabric Must also select PN I IHEADADAPTER Universal Headrest Adapter For aftermarket headrests. I10552 Adj Removable - Headrest Hardware (1 Each) ADP $ Code SEHND0020 Page 9 of 16

10 Accessories I UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each) "W x 7"T Curved Pad. Must also select PN I I UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) "W x 8"T Flat Pad. Must also select PN I I10553 Adj Removable - Amp Support Hardware (1 Each) Please indicate if you would like the amputation support mounted on the right or left side of the seat frame: I Mount Amp Suppt on Left: Mount Amp Suppt on Right: UT Hip Suppt (B) w/ Mesh Cover - High (Pair) "W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I UT Hip Suppt (A) w/ Mesh Cover - High (Pair) "W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) "W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) "W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) "W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I10550 Adj Removable - Thigh Support Hardware (Pair) I Abductor Kit - Leatherette Must also select PN I I10555 Adj Removable - Abductor Hardware (1 Each) I10783 Hand Heater Kit with Buddy Button Kit includes Hand Heater (2"H x 1.5"W x 2.75"D), Buddy Button, Power Cable with XLR Plug and PERMOfix Mounting Adapter. Heater has three temp/fan speed settings. For best results, a hand cone (I10784 or I10785) is recommended to trap heat around the user's hand(s). To ensure best positioning for the user, heater will NOT be mounted when chair is I10784 received. One-Hand Cone Kit with PERMOfix Mounting Set Clear plastic dome (5.5"W x 13.5"L x 8"H) with forearm opening at one end. Kit includes PERMOfix mounting hardware to attach cone to end of armrest. To ensure best positioning I10785 for the user, cone will NOT be mounted when wheelchair is received. Two-Hand Cone Kit with Mounting Pins Clear plastic triangular dome (15"W x 12.5"L x 8"H) with two forearm openings. Use with Upper Extremity Support is recommended. Kit includes four pins to secure cone to tray surface. Pins remove without tools for easy transfers. To ensure the best positioning for the user, cone will NOT be mounted. I Transfer Handles, Corpus 3G Seat I Push handles, Corpus 3G Seat I Cup/Cell Phone Holder I Self-Leveling Cup Holder I Medical Necessities Bag Hooks - UniTrack I Medical Necessities Bag Includes hardware to attach bag to backrest. I Bodypoint Monoflex Large Chest Support Belt Kit "L x 4.5"W Pad Size. Item will be shipped as parts. I Bodypoint Monoflex Medium Chest Support Belt Kit "L x 4"W Pad Size. Item will be shipped as parts. I Bodypoint Monoflex X-Lrge Chest Support Belt Kit "L x 5"W Pad Size. Item will be shipped as parts. I Upper Extremity Support Angle Adjustable 20"W I Upper Extremity Support Angle Adjustable 22"W I10556 Adj Removable - Tray Hardware (1 Each) Page 10 of 16 ADP $ Code SEFND0005 SEFND0005 SELND0015 SELND0015 SELND0015 SESND1043

11 Accessories I Oxygen holder I Crutch holder Stealth Accessories I10869 Stealth Ultra Headrest Includes Stealth Occipital pad (500 series), Sub Occipital pad (600 series) and Flip Down Headrest Mount (TWB480-QFDM). Select Stealth headrests accessories and alternative I10800 drive mounts to complete headrest assembly. Stealth Swing Away Egg Switch for Ultra Headrest Includes Black Egg Switch and Stealth Ultra Swing Away Hardware (SUS9-R). Please indicate if you want switch mounted on left or right side of headrest: I10893 Mount Switch on Left: Mount Switch on Right: Stealth Swing Away Tash Micro Lite for Ultra Includes Tash Micro Lite Switch and Stealth Ultra Swing Away Hardware (SUS9-R). Please indicate if you want switch mounted on left or right side of headrest: I10801 Mount Switch on Left: Mount Switch on Right: Stealth Swing Away Facial Supprt Hdw for Ultra Must also select support pad (I10810, I10811, I10812). Please indicate if you want it mounted on left or right side of headrest: Mount Hardware on Left: Mount Hardware on Right: I10810 Stealth #900 Support Pad (4.5" x 2") - Ultra I10811 Stealth #910 Support Pad (3" x 2") - Ultra I10812 Stealth #920 Support Pad (6.4" x 2") - Ultra I10718 Stealth Comfort Plus Headrest - 8"W Must also select I I10719 Stealth Comfort Plus Headrest - 10"W Must also select I I10720 Stealth Comfort Plus Headrest - 14"W Must also select I I10721 Adj Stealth Headrest Hardware - Each (TWB480) Please select the headrest post length below: Standard I10736 length (10"): Short length (6"): Stealth Swng Away Egg Sw for Comfort Plus Headrest Includes Black Egg Switch and Stealth Comfort Plus Swing Away Hardware (CPS9-R). Please indicate if you want switch mounted on left or right side of headrest: I10894 Mount Switch on Left: Mount Switch on Right: Stealth Swing Away Tash Micro Lite for Cmfrt Plus Includes Tash Micro Lite Switch and Stealth Comfort Plus Swing Away Hardware (CPR9-R). Please indicate if you want switch mounted on left or right side of headrest: I10809 Mount Switch on Left: Mount Switch on Right: Stealth Swing Away Facial Supprt Hdw for Cmfrt Plus Must also select support pad (I10813, I10814, I10815). Please indicate if you want it mounted on left or right side of headrest: Mount Hardware on Left: Mount Hardware on Right: I10813 Stealth #900 Support Pad (4.5" x 2") - Cmfrt Plus I10814 Stealth #910 Support Pad (3" x 2") - Cmfrt Plus I10815 Stealth #920 Support Pad (6.4" x 2") - Cmfrt Plus I10936 Stealth 4" x 6" Lateral Spprts, Original Hdwr, HD Must also select I Kit contains the original Stealth link hardware with swing away brackets and two height adjustmest rails. The rails are bolted to the back side of the backrest to provide mounts for the lateral hardware. I10723 Adj Removable Stealth Lateral Hardware (Pair) Alternative Drive Systems Page 11 of 16 ADP $ Code ADP $ Code

12 Alternative Drive Systems ALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS: I10751 Mini-Joystick for Omni / IOM (9-pin connector) 2, Operating Force = 13 g Neutral to Full Deflection = 5mm I Compact Joystick for Omni / IOM (9-pin connector) 1, Operating Force = 220 g Neutral to Full Deflection = 28mm Joystick includes two 3.5mm mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam I Ball Knob. Compact Joystick LITE for Omni / IOM (9-pin conn) 1, Operating Force = 50 g Neutral to Full Deflection = 17mm Joystick includes two 3.5mm mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob. CHOOSE MOUNTING HARDWARE: I Alt. JS Adjustable Mount Kit - Armrest I Mount in front of Left Arm: Mount in front of Right Arm: Alt. JS Adjustable Mount Kit - Midline I Mount on Left Arm: Mount on Right Arm: Alt. JS Adjustable Mount Kit - Chin Boom Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge I10752 may be applied if ordering lower backrest heights. Alt. JS Adjustable Mount Kit - Haims Harness, Lrg For neck width up to 19cm. I10753 Alt. JS Adjustable Mount Kit - Haims Harness, Sml For neck width up to 14cm. I10754 Alt. JS Adjustable Mount Kit - Haims Harness, Peds For neck width up to 10cm. I10068 Alt. JS Adj. Mount Kit - Power SwingAway Chin Boom 4, Includes power swing away mount off the backrest with adjustable mounting hardware. I10795 Custom charge may be applied if ordering lower backrest heights. Stealth Swing Away Chin Boom for Ultra Headrest Includes Stealth Ultra Swing Away Hardware, 18" boom and bracket for attaching a Mini Joystick or Compact Joystick. Please indicate which bracket to include and if you want boom mounted on left or right side of headrest: Mini Joystick Bracket: Compact Joystick Bracket: I10797 Mount Boom on Left: Mount Boom on Right: Stealth Sw Away Chin Boom for Comfort Plus Headrest Includes Stealth Comfort Plus Swing Away Hardware, 18" boom and bracket for attaching a Mini Joystick or Compact Joystick. Please indicate which bracket to include and if you want boom mounted on left or right side of headrest: Mini Joystick Bracket: Compact Joystick Bracket: I10807 Mount Boom on Left: Mount Boom on Right: Stealth Gatlin Eclipse Tray w/ Mini JS Mount Designed to mount on Stealth Gatlin Mid Line Mounts. Includes bracket for mounting a Mini Joystick under tray. Through hole in tray surface provides joystick access. Please indicate side of tray for hole position: Position Hole on Left: Position Hole on Right: ALT JOYSTICK ACCESSORIES: I Dual Switches for Compact Joystick - Fixed Mount Includes two pushbutton switches mounted on rigid Switches can be used for Mode & On/Off. Switch operation force = 130 g Mount at front of Joystick: Mount at rear of Joystick: I Mount at left of Joystick: Mount at right of Joystick: Dual Switches for Compact Joystick - Gooseneck Mnt Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are positioned on Left and Right sides of Compact Joystick. Switches can be used for Mode & On/Off. Switch operation force = 130 g ADP $2, Code ADP $ Code ADP $ Code Page 12 of 16

13 Alternative Drive Systems TOTAL CONTROL HEAD ARRAY SYSTEM: I Permobil Head Array - 3-switch Basic System 4, Includes Short Adjustable Lateral Arms with Proximity Sensors mounted in Upper Left and Upper Right positions. Short arms can be adjusted from 5.5" to 8" long. ** Complete the Head Array system by choosing pads, hardware and accessories below. ** Choose Omni Control Module (3-sw/5-sw) or R-net Input Module (5-sw only) separately. CHOOSE OCCIPITAL PAD SIZE (REQUIRED) I Small Occipital Pad for Head Array "W x 3"H I Large Occipital Pad for Head Array - 6"W x 4"H. CHOOSE OCCIPITAL PAD MOUNT (REQUIRED): I10847 Fixed Mount for Occipital Pad - Head Array I Adj. Swivel Mount for Head Array Occipital Pad Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms. CHOOSE BACKREST MOUNTING HARDWARE (REQUIRED): I Stealth TWB480 Backrest Mounting Hdwr with Links Please select the length of the vertical stem below: Standard length (10"): Short length (6"): I Stealth TWB480 Backrest Mtng Hdwr with Flipback I Stealth HMO475 Backr Mtng Hdwr w 17mm Ball I10848 Stealth TWB480 Backrest Mnt Hdwr w SubOcptl Mount I10855 Stealth 600 SubOccipital Pad - 8.5" W x 2.75" H Must select when PN I10848 is ordered. ADP $4, Code SELECT LOWER LEFT ARM PACKAGE (OPTIONAL): I10859 Add Lateral Arm to Lower Left of Head Array Must also select Sensor, Switch or Solid Pad. Choose Lateral Arm Adjustment Range: Short (5.5" - 8"): Long (9" "): I10861 Add Proximity Sensor to Lower Left Lateral Arm Since Proximity Sensors require power, they CANNOT be used as On/Off switches. I Add Egg Switch Assm to Lower Left Lateral Arm I Add Solid Pad to Lower Left Lateral Arm SELECT LOWER RIGHT ARM PACKAGE (OPTIONAL): I10860 Add Lateral Arm to Lower Right of Head Array Must also select Sensor, Switch or Solid Pad. Choose Lateral Arm Adjustment Range: Short (5.5" - 8"): Long (9" "): I10862 Add Proximity Sensor to Lower Right Lateral Arm Since Proximity Sensors require power, they CANNOT be used as On/Off switches. I Add Egg Switch Assm to Lower Right Lateral Arm I Add Solid Pad to Lower Right Lateral Arm HEAD ARRAY ACCESSORIES: I Proximity Sensor + Swivel Assm - Not Mounted Since Proximity Sensors require power, they CANNOT be used as On/Off switches. I Egg Switch + Swivel Mount Assm - Not Mounted I Solid Lateral Pad+Swivel Joint - Not Mounted I mm Ext. Cable for Sensor/Switch, 0.3m Long I mm Ext. Cable for Sensor/Switch, 1m Long I mm Ext. Cable for Sensor/Switch, 2m Long I mm Ext. Cable for Sensor/Switch, 3m Long Page 13 of 16 ADP $ Code

14 Alternative Drive Systems HEAD ARRAY ACCESSORIES: I mm Y-splitter Cable for Sensor/Switch Allows two Proximity Sensors/Mechanical Switches to connect to the same direction jack. I10858 PERMOfix Mount Kit for Sensor/Switch on UT Rail Enables Sensors/Switches with Swivel Assemblies to be mounted to UniTrack Rails. Kit includes one PERMOfix joint with Flat Plate, hardware to mount to UT rail, one PERMOfix joint with 90 swivel adjustment and two 4" rods. SIP & PUFF SYSTEMS: I10573 Sip & Puff System for Omni 1, Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath I10574 tube kit. Sip & Puff System with Fiber Optic Opti-Stop 2, Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath I10762 tube kit. Adjustable Mounting Hrdw - Sip & Puff Required when selecting PN I10573 or I $36.00 ADP $1, Code WEX5 WEX5 ALTERNATIVE PROPORTIONAL CONTROL SYSTEMS: I10763 VIC Proportional Finger Control for Omni / IOM 2, The VIC CCD translates small finger movements into proportional driving commands. I10764 VIC Adjustable Mount Kit - Armrest I10765 Mount in front of Left Arm: Mount in front of Right Arm: VIC Adjustable Mount Kit - Midline Mount on Left Arm: Mount on Right Arm: I10317 Proportional Tablet Control for Omni / IOM 4, The Tablet Control is a unique drive input which enables a user to control a power wheelchair in a very similar manner to a mouse being controlled by a touchpad on a laptop computer. The dimensions of the Tablet Control Pad are: 30cm Wide x 24cm Long x 4cm Thick Kit also I10767 includes: Buddy Button Switch, and Tablet Control Mounting Bracket. Proportional Foot Control 2, I10766 Mount on Left: Mount on Right: Adjustable Mounting Hrdw - Foot Control Required when selecting PN I I10638 RIM Control - SwitchIT for Omni 5, Requires Omni Control Module. Cannot use this part with an Input Module. I10770 Adjustable/Removable Hardware - RIM Control Required when selecting PN I Alt Drive Systems Setup CHOOSE OMNI OR INPUT MODULE (REQUIRED): ID51154IR Omni Control Module for R-net w/ Infrared 2, Mount in front of Left Arm: Mount in front of Right Arm: Please specify which type of alternative drive input you will be using if not ordering the input device from I10577 Permobil. Input Device: Adjustable Swing-Away Hardware - Omni Required when selecting Part Number ID51154IR. I10581 Input Module (IOM) for R-net Control System 1, This device allows a proportional or switched drive input to be connected to an R-net Control System without the use of an Omni. It must be ordered in conjunction with an R-net Remote Joystick. It does NOT support any of the following input devices: Sip-n-Puff, 3-Switch Head Array or RIM control. ADP $2, Code ADP $2, Code Page 14 of 16

15 Alt Drive Systems Setup CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX: I10080 Mount Seat Control Switchbox on Backrest I10079 Mount Seat Control Switchbox on Left I10078 Mount Seat Control Switchbox on Right Alt Drive Accessories IMICROSWITCH Microlite Switch Qty: IBUDDYBUTTON Buddy Button Qty: I5808 Mini Cup Switch Qty: IZTS-P Proximity Switch Qty: IMINIJOY5SW Mini Joystick 5 Switch OC I10771 Touch Contact with CR2032 Battery Qty: I10772 Dome Switch, Backrest Mnt w Gooseneck Qty: Mount on Left: Mount on Right: Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest heights. Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45 swivel adjustment, one 150mm rod, one 200mm rod and one 225mm gooseneck switch with I m cable and mounting clamp. Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty: Mount on Left: Mount on Right: w 90 Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45 swivel adjustment, two 6" rods, one 90 Swing-Away joint, one 9" gooseneck switch w 50" cable and mounting clamp. ADP $ Code Page 15 of 16

16 Notes & Additional Instructions: Chair Order Policy: You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at The order cannot be processed without the following: -A client name or code, the client s measurements, the client s weight -The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, LTD. is not responsible for configuration or size discrepancies resulting from customer errors on the order form. -Order confirmations will be provided by Permobil 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. Order Acknowledgement: I,, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy and may carry additional charges. Signed: Printed Name: Title: Date: NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any parts ordered for service or future alterations will carry different pricing and warranty. MID PROFILE Cushion is a registered trademark of the The ROHO Group. The ADP codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer. Page 16 of 16