q Little Wave Flip XP-Rigid Base E1233, E1161 $
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1 Funder: Therapist: Date: q MOH q ACC Marked For: Details: Ship To: Address: City: Postcode: Phone: Notes: q Little Wave Flip XP-Rigid Base E1233, E1161 $ 74 kg weight capacity. Price includes one time free growth kit. Tilt range: 0º - 45º. q Little Wave Flip XP-Folding Base E1234, E1161 $ 74 kg weight capacity. Price includes one time free growth kit. Tilt range: 0º - 45º. Frame Frame Width Select box corresponding to desired Frame Width Frame Width q 10 q 11 q 12 q 13 q 14 q 15 q 16 q 17 q 18 Select in desired Range Range Short q 12 q 13 q 14 q 15 q 16 Medium q 14 q 15 q 16 q 17 q 18 Effective 01/10/2018 Transit Option q Transit System K0108 N/C Offset Hanger Option q Offset Hanger $ Available only Rigid Base. Not available 12. Tilt Mechanism q Hand N/C q Foot N/C Long q 16 q 17 q 18 q 19 q 20 $ Backrest Back Post / Height Range / Back Height Select Back Height in row corresponding to desired Back Post and Height Range Back Post Price Height Range Stroller Handle Back Post (Folding) N/C Short q 20 Tall q 24 Back Height Fixed Height Adjustable Handle 1 (Folding) N/C Short q 22 Tall q 26 Adjustable Height Adjustable Handle (Folding) 1 Not available Seating Dynamics Rocker Back $ Short 1 q 18 q 19 q 20 q 21 q 22 q 23 q 24 q 25 Tall q 20 1 q 21 1 q 22 1 q 23 q 24 q 25 q 26 q 27
2 Backrest continued Stroller Handle Back Post Option Available only Stroller Handle Back Post q Removable Stroller Handle Extension $ Footrest Hanger / Front Frame Bend q 60º N/C Available only Extension Tube Hangers q 70º N/C q 80º N/C Not available 8 Casters q 90º N/C Available only Front Mount Hangers. Not available 8 Casters. q Pro Elevating Leg Rests (PRO ELR) E0990 $ Not available Frame Widths less than 14 out Offset Hangers or Frame Widths less than 12 Offset Hangers q Omit Hangers - $ Other Backrest Options q Non Folding Back N/C Standard Seating Dynamics Rocker Back q Seating Dynamics Rocker Back K0108 $ Not available Flip Up Armrests. Available only Non Folding Back. q Adjustable Height Rigidizer Bar $ Footplate q Composite N/C Not available Front Mount Hangers, Frame Widths less than 14 out Offset Hangers, Frame Widths less than 12 Offset Hangers or PRO ELR q Composite Angle Adjustable K0040 $ Not available Front Mount Hangers or Frame Widths. 13 and 14 Frame Widths require Offset Hangers. q Aluminum Angle Adjustable K0040 $ q One Piece Flip Up Angle Adjustable K0040 $ Not available Front Mount Hangers, PRO ELR, Frame Widths less than 14 out Offset Hangers or Frame Widths less than 12 Offset Hangers Footrest / Extension / Seat to Footrest Length Select Seat to Footrest Length in row corresponding to desired Footrest and Extension. Footrest Length of at least 2.5 shorter than Front Seat Height recommended. Extension Tube Hanger measurements based on 70º Hanger Bend. Footrest Extension Seat to Footrest Length Extension Tube Hangers (60º, 70º, 80º) Short q 10 q 10.5 q 11 q 11.5 q 12 q 12.5 q 13 q 13.5 Medium q 11.5 q 12 q 12.5 q 13 q 13.5 q 14 q 14.5 q 15 q 15.5 Long q 14 q 14.5 q 15 q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 Front Mount Hangers 1 Short (70º, 80º, 90º) Medium (70º, 80º, 90º) Long (70º, 80º) Standard Selections Requires 3 Extension for $ q 5 q 5.5 q 6 q 6.5 q 8.5 q 9 q 9.5 q 7 q 7.5 q 8 q 10 q 10.5 q 11 q 5 q 5.5 q 6 q 6.5 q 7 q 7.5 q 10.5 q 11 q 11.5 q 8 q 8.5 q 9 q 9.5 q 10 q 12 q 12.5 q 13 q 5 q 5.5 q 6 q 6.5 q 7 q 7.5 q 8 q 8.5 q 12.5 q 13 q 13.5 q 9 q 9.5 q 10 q 10.5 q 11 q 11.5 q 12 q 14 q 14.5 q 15 PRO ELR Low Pivot Short q Long q PRO ELR High Pivot Short q Long q Available only Aluminum Angle Adjustable Footplates. See Minimum Front Seat Height chart below. Minimum Front Seat Height Front Mount Hangers Hanger Length Short Medium Long Hanger Bend 70º 80/90º 70º 80/90º 70º 80º Minimum Front Seat Height Standard Selection Minimum Front Seat Height 3 Extension Extension Available only Front Mount Hangers. Provided as parts. q 3 Extension for Front Mount Hanger $
3 Footrest continued Heel Loop q Heel Loops E0951 $ Not available One Piece Flip Up Angle Adjustable Footplates, Frame Widths less than 14 out Offset Hangers or Frame Widths less than 12 Offset Hangers q Adjustable Heel Loops E0951 New! $ Not available One Piece Flip Up Angle Adjustable Footplate, Frame Widths less than 14 out Offset Hangers or Frame Widths less than 12 Offset Hangers q Omit Heel Loops N/C Calf Strap q Velcro Adjustable K0038 $ q Padded Velcro Adjustable K0038 $ q Bodypoint Padded AeroMesh K0038 $ Residual Limb Support Residual Limb Support E1020 q Left $ q Right $ q Omit Left Hanger - $ q Omit Right Hanger - $ Cover q Smooth q Air Mesh q Smooth q Air Mesh Pad Size q 5 x 8 q 9 x 14 q 5 x 8 q 9 x 14 q 7 x 10 q 11 x 10 q 7 x 10 q 11 x 10 q 9 x 10 q 11 x 14 q 9 x 10 q 11 x 14 Hanger Release If no selection is made 4-Way - In line will be used hangers or Classic will be used PRO ELR q Classic Std q 4-Way - In line N/C See reference A to the right. Allows chair to be folded out removing footrest hanger. Not available PRO ELR. q 4-Way - Out N/C See reference B to the right A B
4 Seat Height, Casters and Rear Wheels Seat Height / Caster Size / Rear Wheel Size Select Seat Height corresponding to desired Rear Wheel and Caster Size Rear Wheel Size 12 Pneumatic or Pneumatic Airless Insert 12 Full Poly 16 Pneumatic, Pneumatic Airless Insert or Full Poly 16 Low Poly Caster Size x x 2 Seat Height q 13.5 q 14 q 14 4 q 14 4 q 14.5 q 14.5 q 14.5 q 15 q 15 q 15 q 15 4 q 16 q 16 q 16 q 16 q 17 q 17 q 17 q 17 3 q 17 3 q 17 3 q 13.5 q 14 q 14.5 q 14.5 q 14.5 q 15 q 15 q 15 q 16 q 16 q 16 q 16 q 16 4 q 16 4 q 17 q 17 q 17 q 17 3 q 17 3 q 17 3 q 15 q 15 q 15 q 15 4 q 16 q 16 q 16 q 16 q 16 4 q q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q q q q q 14 q 14 4 q 14 4 q 14.5 q 14.5 q 14.5 q 15 q 15 q 15 q 16 q 16 q 16 q 16 q Self Propel Axle Plate selections limit tilt range 2 Not available 12 3 Not available Not available Not available in combination Spoke wheels and Full Poly Rear Type 6 Not available in combination Spoke wheels, Full Poly Rear Type and Not available in combination Mag wheels and Not available in combination Spoke wheels, Pneumatic tires and requires Spoke wheels and Full Poly Rear Type Rear Wheel Size 16 Drum Brake Self Propel 22 1 Self Propel 24 1 Self Propel Caster Size x x 2 Seat Height q 15 q 15 q 15 q 16 q 16 q 16 q 16 q 16 q 16 3 q q 18.5 q q q 18.5 q q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 20 q 20 4 q 20 4 q 20 q 20 q 20 q 16 q 16 q 16 q 16 q 16 q 16 q q 18.5 q 18.5 q q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q q q q q q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q ,8 q 19.5 q 19.5 q q ,8 q 19.5 q 20 5 q 20 6 q 20 6 q 20 q 20 q 20
5 Seat Height, Casters and Rear Wheels continued Caster Type q.75 Lighted Rollerblade $ Not available 6", 7 and 8" Caster Sizes q 1 Poly N/C q 1 Poly Aluminum $ Not available 6, 7 and 8 Caster Sizes q 1 Pneumatic $ Not available 5 and 7 Caster Sizes q 1.5 Poly $ Not available 7 and 8 Caster Sizes q 1.5 Soft Roll Aluminum $ Not available 7 and 8 Caster Sizes q 2 Poly $ Not available 5, 7 and 8 Caster Sizes q 2 Pneumatic w/ Foam Insert E2217 $ Not available 5, 6 and 7 Caster Sizes Axle No selection needed Drum Brake q Fixed N/C Not available Folding Base Frame and Standard Wheel Locks q Quick Release N/C Rear Wheel Type q Mag (Black) N/C q Colored Mag $ Available only in 20 and 22 rear wheels Color: q Florescent Red q White q Blue q Pink q Spoke $ Not available in 12 or 16 rear wheels Wheel Locks Wheel Lock q Push to Lock N/C Rear wheels must be removed to fold chair this wheel lock selection. q Pull to Lock N/C Not available 12 or 16 Full Poly tires. Rear wheels must be removed to fold chair this wheel lock selection. q Attendant Foot Lock N/C Available only 12 and 16 Mag wheels. q Drum Brake E2228 $ Not available Hand Tilt Mechanism or 16 Low Poly tire. Available only 16 rear wheel. Axle is Quick Release. q Omit Wheel Locks N/C Rear Type q Full Poly E2218 N/C q Low Poly E2218 N/C Available only 16 rear wheel q Pneumatic E2211, E2212 $ q Pneumatic Airless Insert E2211, E2213 $ Handrim Handrims not available on 12 or 16 rear wheels Standard Handrims q Aluminum Anodized Std q Plastic Coated $ q Projection (8 Vertical Projections) $ Available on 24 rear wheel q Omit Handrims N/C Natural Fit Handrims Not available on 20 rear wheel or 22 Mag wheels. Not recommended Mag wheels. q Natural Fit LT Regular Grip $ q Natural Fit Standard Regular Grip $ q Natural Fit LT Super Grip $ q Natural Fit Standard Super Grip $ q Natural Fit LT Omit Grip $ q Natural Fit Standard Omit Grip $ Handrim Option Not available on Plastic Coated or Projection Handrims q 3M Micro Grip $ Wheel Lock continued Dual - Attendant Foot Lock $ Available only 12 and 16 Mag wheels. Rear wheels must be removed to fold chair this wheel lock selection. q Push to Lock q Pull to Lock Dual - Drum Brake $ Not available Hand Tilt Mechanism or 16 Low Poly tire. Available only 16 rear wheel. Axle is Quick Release. Rear wheels must be removed to fold chair this wheel lock selection. q Push to Lock q Pull to Lock Wheel Lock Options q Extension Handles E0961 $ Available only Push to Lock or Pull to Lock Wheel Locks.
6 Armrests Armrests Please select Arm Pad option q Height Adjustable Pediatric Desk (6.5-9 ) E0973 $ Best fit s less than 14 q Height Adjustable Pediatric Desk Tall ( ) E0973 $ Best fit s less than 14 q Height Adjustable T-Arm ( ) E0973 $ Not available 12 q Height Adjustable T-Arm Low ( ) E0973 $ Not available 12 q Angle Adj. Locking Extendable Flip Up ( ) E0973 $ Not available Seating Dynamics Rocker Back Accessories Removable Side Guard Not available Height Adjustable Armrests q Adult Composite Side Guards (14-16 ) K0108 $ q Pediatric Composite Side Guards (10-14 ) K0108 $ Positioning Belt q 1 Auto Buckle E0978 $ q 1 Padded Auto Buckle E0978 $ q 1 1/2 Auto Buckle E0978 $ q 1 1/2 Padded Auto Buckle E0978 $ q 2 Airline Buckle E0978 $ Belt Mounting Kit q Bodypoint 1 Band Clamp Belt Mounting Kit $ q Seat Belt Mounting Hardware $ Anti-Tip q Rear Anti-Tips E0971 $ Color Arm Pad Arm Pads not available Tubular Flip Up Armrest. Full Arm Pad not available Height Adjustable Pediatric Desk Armrests. Standard Arm Pad N/C q Desk q Full Waterfall Arm Pad $ q Desk q Full Not available Angle Adjustable Locking Flip Up Extendable armrests Foam Grip N/C q Desk q Full Available only Angle Adjustable Locking Extendable Flip Up Armrest Armrests Continued q Tubular Flip Up N/C Not available Seating Dynamics Rocker Back q Omit Armrests N/C Seat Pan q Growing Solid Seat Pan E2231 $ Spoke Guards q Clear Spoke Guards K0065 $ Not available Mag wheels q Black Spoke Guards K0065 $ Available only 22 and 24 Spoke wheels Designer Spoke Guards K0065 $ Available only 20 and 22 Spoke wheels Design: q Blue Monster q Fairy Garden q Havin a Hoot q Robo Fun q Rockin Reptiles q Super Puppies q Tutu Cute q Tuxedo Time Other Accessories q Tool Kit $ q Removable Underseat Pouch $ q Pediatric Ki Mobility Backpack $ q Ki Mobility Backpack $ q Black Neoprene Impact Guards $ q Tilt Stop Posterior (Pair) K0108 $ q Tilt Stop Anterior (Pair) K0108 $ Available only Rigid Base Frame and Accent Select desired frame and accent colors. Accent color is used on side panel; if no accent color is selected, frame color will be used. Gloss Finish Frame Accent Matte Finish Frame Accent Black N/C q q Army Green N/C q q Blue Skies N/C q q Charcoal Gray N/C q q Bubblegum Pink N/C q q Emerald Green N/C q q Candy Blue N/C q q Iridescent Burgundy N/C q q Candy Purple N/C q q Iridescent Navy N/C q q Candy Red N/C q q Retro Red N/C q q Copper N/C q q Royal Blue N/C q q Fuchsia N/C q q Shadow Black N/C q q Granny Smith N/C q q Smooth White N/C q q Metallic Orange New! N/C q q Silver N/C q q Teal N/C Yellow N/C q q q q
q Little Wave Flip XP - Rigid Base KF-XPRIGID $
Phone 0800 5 222 Fax 0800 275 65 Effective /06/207 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Little Wave Flip XP - Rigid Base KF-XPRIGID $ 9.8kg weight capacity. One time free
Frame Width. Seating Setup. q 16 q 15 q 14 q 17 q 16 q 15 q 14 Short q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14
Phone 0800 5 Fax 0800 5 365 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Focus CR $ 36kg weight capacity. Tilt range: -5º anterior to 50º posterior. Effective /0/0 Ship To: Address:
q 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
Frame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.
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
Sling 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
YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
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MASS 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
MASS 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
MASS 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
MEDmobility 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
Little Wave Flip Accessory Flip Chart
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2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids
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NXT Pediatric. Manual Wheelchair. Transport Optional Base
Pediatric Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Transport Optional Base Folding (E1234) NXT-30300 $2800 Transport Optional Note: Transportation Option selected
4.6. 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:*
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair
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Spark Accessory Flip Chart
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Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg
QUICKIE IRIS Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: E-Mail: E-Mail: Tel: Fax: Tel: Order date: Marked for: Purchase order: Number required: Sunrise order no: Base
Quickie IRIS January 2014
Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: ZIP: Address: Dealer Phone: ( ) Fax: ( )
STD +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:*
Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN
4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:
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
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair
P.R.O. CG Adult Manual Wheelchair TM SE 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com email: customerservice@freedomdesigns.com Date: Buyer: Company:
4.2 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
Quickie QX December 2018
Quickie QX December 2018 EIF6 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV:
Quickie QX July 2017
Quickie QX July 2017 EIF6 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: Dealer
Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
Quickie QXi AADL EIF6, October 2018 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City:
Condor Script Form Folding Frame Day Wheelchair 90050
90050 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
3 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.
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG
P.R.O. CG 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com Date: PO# Adult Manual Wheelchair TM SE Date: Buyer: Company: Email: Quote Order PO# Location:
4.6. Clinician/ATP/RTS: City: State: VEMA039 * Required. Veloce - FRONT Seat-to-floor height. 16 to 19 Specify desired height: 80.
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:*
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required MVMA053 MVMA056. MVMA058 English Manual (STD) Dutch Manual
160 Armand-Majeau Sud 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 4.8 MOVE ORDER FORM - INTERNATIONAL P.O.
Condor Script Form Folding Frame Day Wheelchair 90050
90050 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
4.8. Name: K0005. Stem bolt Length /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
APEX 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:*
VELOCE 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Caster sizes Height available +- 1/4" 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 VELOCE ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY.
CATALYST UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY. INNOVATIVE AND PATENTED FRAME DESIGN Catalyst frames are constructed from 7000 series aluminum. A stronger
MOVE ORDER FORM - CANADA
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:
ORDER 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:
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows.
This form must be opened in dobe crobat. The Submit Form button will not work from most browser windows. Company: ccount Number: Date: Quote PO Number: RTS: Ship To: ddress: City: State: Zip: Phone: Marked
Stallion Script Form Fixed Frame Adjustable Wheelchair 90100
90100 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
C2 FRONT Seat-to-floor Height - Please select your choice. Custom Technologies Limited. 40 Raywood Crescent TAUPO. New Zealand
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.
STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required KDMA063 English Manual (STD) Manuel Français
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:*
BENTLEY. Order Form - AADL - W322 Prices in Canadian Dollars. October 1, W h e e l L o c k s. A n t i - T i p p e r s. B a c k P o s t S t y l e
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Tag Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a m e T y
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: Phone:
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 MOVE ORDER FORM - CANADA
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: City: Province:
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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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 4.6 APEX ORDER FORM - International 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 4.7 Helio A6 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 Helio A6 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 4.6 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 4.8 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 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 4.7 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 KIDS ORDER FORM - CANADA P.O. number:*
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