Serial Number: Manufacturing Date: /20

Similar documents
RGK Tiga Sub4. July Serial Number: Manufacturing Date:

Serial Number: Manufacturing Date: /20

Serial Number: Manufacturing Date: /20

Serial Number: Manufacturing Date: /20

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

MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:

Frame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.

Please make your selection with a cross in the box Standard feature Free of Charge

MASS Script Form. Frame. Backrest. Seat Depth

MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.

SEATING CHOICE TITANIUM FRONT FRAME

Küschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone)

champion Standard Base Price 1,875 Standard Features

k-series Aluminium Standard Features

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:

champion carbon Customer weight = Kg Code X Description Dealer SEATING CHOICE DDF0204 küschall Champion Carbon 85 Frame Angle

RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"

Condor Script Form Folding Frame Day Wheelchair 90050

SEAT BACKREST. REAR SEAT HEIGHT SELECTION: independant of rear wheel size. Rear seat height in cm (2)

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.

Stallion Script Form Fixed Frame Adjustable Wheelchair 90100

4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)

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:

Max. user weight: 110Kg / 140kg USER WEIGHT Fax number: +44 (0)

Order Date : carbon. Tension adjustable seat, option DDA0611 is not possible with seat width 320mm

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:

Küschall Champion DEALER Maximum user weight 120kg (19 Stone)

Küschall K Series DEALER Maximum user weight 120kg ( 19 Stone )

APEX 4.6. FRONT Seat-to-floor height Caster sizes Height available +- 1/4" ORDER FORM - International. 3" Caster. Specify desired height:

Order Form. English Company stamp. Version mudguard (AVAILABLE ONLY WITH REAR WHEELS 24'') Version straight sideguard

This wheelchair has a weight limit of 80kg

Condor Script Form Folding Frame Day Wheelchair 90050

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:

Town: Postal code: Town: Postal code: CLIENT MEASUREMENTS. Seat Width in cm 38 cm 40 cm 42 cm 44 cm 46 cm. 40 cm

YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.

This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.

ORDER FORM Ver.6 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:

noir 2.0 Order Form NONO Carbon fibre frame made-to-measure. English Company stamp Date User name Responsible Seat depth (PS)

1,795. Base Price. Part no.: CLIENT MEASUREMENTS. Town: Postal code: Town: Postal code: Tel: Fax: Tel: Fax: Purchase order:

4.6. Clinician/ATP/RTS: City: State: C2MA029 * Required

Wheelchair Portfolio. Active wheelchair

Manual Wheelchair Pencoed Technology Park. DEALER Prescription form Pencoed. CF35 5AQ. LPF1U2ULTRALIGHT211113D Tel: Fax:

Additional Front Wheel Options Not Shown FW1 3 x.75 Micro-Caster FW14 4 x.75 Plastic Wheel w/poly Tire FW3 4 x.75 Light-Up Micro-Caster

STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD

Küschall Champion DEALER Maximum user weight 120kg (19 Stone)

Invoice address: same as company address. Invoice address: other (see below) Cust. no.: Name: Street: Postcode, city: Phone: Fax: Contact:

MASS Script Form. 160 Kg Weight Capacity Charge. Transit Option. 136 Kg maximum weight capacity. Not available with Removable Seat Pan.

Transformer. Rev C. Aug 15, 2010 Page 1 of 8

Zippie Zone July 2018 EIRZ1

SPEEDY 4all "Classicline"

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:

TiLite. Please Fax to the TiLite Customer Service Team at or

COST EFFECTIVENESS THERAPEUTIC BENEFITS APPLICATIONS. the optimal smoothness and lightweight design facilitate the independence of the user

Voyager Evo. Rigid-frame active wheelchair. Standard equipment. Canada: Fax: Order Form and Price List

Account Number: Provider Name: Contact:

Account Number: Provider Name: Contact:

4.6. Clinician/ATP/RTS: City: State: VEMA039 * Required. Veloce - FRONT Seat-to-floor height. 16 to 19 Specify desired height: 80.

4.2. Ship to: Vendor: Name: Date: Address: Ordered by: City: Province:

Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,

Quickie Q7 Adjustable March 2014

4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:

BUDDY "Classicline" Active easy running wheelchair

NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.

q Little Wave Flip XP-Rigid Base E1233, E1161 $

Quickie GTX Fixed Frame EIF3, Effective July 2009

Auftrags-Nr.: Order no.: ... Date Signature. MA 110 Standard

Order Form. English Company stamp

Black -01 Moss green -95 Yellow -99. Heather purple -97. Indicate height. Indicate height. Indicate angle. Indicate height: cm. Indicate height: cm

Order Date: SHIP TO Name: Address: : City: Phone: PRICEE

Custom Manual Options & ACCESSORIES AUSTRALIA 2013

Order Date : k-series. titanium. Please make your selection with a cross in the box Standard feature Free of Charge

3 A7WC10 E-Motion adaptor Kit (2 adaptors)

October 2018 EIQ2X. Mark For: Submitting for: Quote Order. ADDITIONAL SHIPPING INFORMATION Dealer Contact: Price. Option # 1. FRAME 002RS1 002RS2

MODEL ZX1 CHARACTERISTICS, POTENCY AND BENEFITS

Top End Crossfire T7A Ultra Lightweight AADL Customers Only Active Performance Adjustable Rigid Wheelchair AADL # W149

Etac Cross 5 and Cross 5 XL

Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)

The lightest folding wheelchair in the world - now with swing away legrests!

lightweight-rigid for handling and performance

Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids

RESIST CONFORMITY. GO ROGUE.

Dealer Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm

Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm

BEARINGS BEARINGS

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

The lightest folding wheelchair in the world

Parts Catalog Issued: Apr 11, Crossfire T7A. Adjustable Rigid Wheelchair

4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required KDMA063 English Manual (STD) Manuel Français

C2 FRONT Seat-to-floor Height - Please select your choice. Custom Technologies Limited. 40 Raywood Crescent TAUPO. New Zealand

4.8. A6MA085 Italian Manual. 3" caster 4" caster. 8" caster Stem bolt Length. + 2,54 cm 1" + 5,08cm 2" STD. 36,8cm 14,5" 34,3cm 13,5" 39,4cm 15,5"

Helio A6 ORDER FORM - CANADA

Helio A6 ORDER FORM - CANADA

UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY.

FOLDING FRAME. Promo Code: City: State: PC: Ship Date: Order #:

IT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE.

HELIUM NEXT GENERATION STYLE

Quickie QX December 2018

Parts Catalog Issued: Apr 11, Crossfire T6A. Wheelchair

Quickie QX July 2017

Transcription:

49 Bespoke Inc. 51 Caldari Road, Units 6-7B Concord, ON L4K 4G3, Canada Telephone: +1.866.827.4548 Fax:+1.877.731.7745 49@49Bespoke.com www.49bespoke.com Distributor Name: Dealers Name: Contact Name: Client's Name: Address: Client's Weight: Client's Height: Postcode: Client's Disability: Country: Telephone: Email: Notes/Coents: Purchase Order No: Delivery Address: Postcode: Contact Name: Telephone: Email: Distributor: FOR RGK OFFICE USE ONLY A/C No: Net Value: $ Freight: $ Who Date Invoice Value: OK to Quote: $ Payment Received: OK to Confrm: $ Document No: DOC Page 1

Base product Mandatory informaton Informaton required for opton Standard confguraton Opton with no extra cost Opton with extra cost SBAXZ010 $ 7,210.00 TIGA Sub4 A7020 XA070 Frame open design Max User Weight 110kg XW010 NC KEY FRAME MEASUREMENTS XY010 Seat width (Ioside of sideguards) (Max - 440) (Mio - 250) XY020 Seat length (Max - 440) (Mio - 250) XY030 XY050 Seat frame additonal length (Provides additooal leg support & haod grip) (Max - 440 total seat) Front frame height (Max - 520) (Mio - 380) XY060 Rear frame height (Max - 500) (Mio - 360) XY070 Frame length (Mio = XY020 + XY030 + 110) (Max - 625) XA020 $ 96.00 Frame ergonomic seat Specify length (Staodard = 120) Page 2

XY080 Front seat taper design FRONT FRAME AND FOOTREST Front Frame Optons Footrest width Specify width Specify width (Optooal, to provide additooal leg support / positooiog) (Wheo combioed with XY080, dimeosioos must be smaller) XY100 Footrest round design (Mioimum 60) Footrest Design & Measurements (Choose One) XY105 Footrest square design (Square desigo allows higher positoo) (Mioimum 60) Please indicate front footrest height: Please indicate front footrest height: 60 80 100 120 60 80 100 120 Iodividual Iodividual Max Height Castor Wheel Max Height Castor Wheel Size Achievable Size Achievable 4" 110 4" 130 Rear footrest height Optmise measurements (Std = Footrest height - 20) Footrest Individual Measurements Footrest length XB010 Optmise measurements (Std = 100) Maximum length 140 Footrest height adjustable lightweight tubular aluminium Footrest Style XB045 Footrest cover lightweight carbon fbre Footrest Cover Page 3

XC135 CASTOR WHEELS, FORKS & WHEEL LOCKS Castor Wheels Castor wheel 4x1.25" aluminium centre with urethane tyre frog legs Choose colour below: Silver hub & black tyre (Std) Black hub & black tyre Green hub & black tyre Red hub & black tyre Purple hub & black tyre Blue hub & black tyre XC190 XY330 Castor fork low ride daily use Black Silver Castor pin width Castor Forks Castor Pin Width Optmise measurements (Mioimum width for clear castor rotatoo aod maximum wheelbase leogth) Wheel Lock Optons SBAXD036 Wheel locks compact scissor with XD010 lightweight fxing Wheel locks omit Sideguard Carbon Fibre Optons SIDEGUARDS Sideguard with Fender Carbon Fibre Optons XE055 Sideguards screw on lightweight carbon fbre XE065 Sideguards screw on lightweight carbon fbre with fender Sideguard Measurements Optmised measurements Sideguard Measurements Optmised measurements Sideguard individual above tyre (Follow tyre) max 25 Sideguard level with tyre (Follow tyre) Fender sideguard height above tyre (Mio = 10) Optmise 10 above tyre (Std if oot iodicated) Fender sideguard to centre of tyre Page 4

Backrest Height - Fixed BACKREST Backrest Design - Fixed Backrest height fxed XG010 Backrest fxed (Noo-foldiog) Specify height Ergonomics - Rearward Positoning (Choose One) XY360 Backrest angle -5-3 0 +3 +5 Iodividual Deg (Max -10/+20 Deg) XG100 Backrest ergonomic $ 116.00 Vertcal height (Mio 250) Ergonomics - Lateral Positoning (Choose One) Rearward positon XG110 Backrest inward taper XG120 $ 116.00 (Above sideguards) $ 116.00 Backrest outward fare (Above sideguards) Width Width Specify Camber Angle CAMBER BAR Fixed Centre of Gravity XY390 Camber angle 1 2 3 SBAXH100 Camber bar fxed positon welded into frame single post (25-125) FRAME FINISH OPTIONS Frame and Footrest SBAXN030 Finish frame brushed SBAXN050 Finish frame polished Accent Colour (Choose One) Finish accent colour black Finish accent colour red Finish accent colour silver Finish accent colour blue Finish accent colour purple XP045 XP035 Upholstery seat sling Sub4 adjustable tension Upholstery backrest Sub4 adjustable tension UPHOLSTERY Seat Upholstery Backrest Upholstery Backrest Upholstery Sttching Optons Silver Black Blue (Staodard if oot iodicated) Red Light blue Other Upholstery Purple XS065 Accessory lightweight Calf Strap Page 5

REAR WHEELS (* non certfed weight optonss Wheel Size XY420 Wheel size 24" XY430 Wheel size 25" Wheel Gap XY460 Rear wheel gap 15 20 25 Wheel Optons XK225 Spinergy Colour Optons Wheel ttanium quick release axle pin (pair) XK075 Black spoke / Black hub White spoke / Black Hub XK180 Spinergy spoke colour custom $ 170.00 (Specify below) Red spoke / Black hub Blue spoke / Black hub Colour inside Yellow spoke / Black hub Green spoke / Black hub Colour outside Wheel Spinergy BLXL 18 blade spoke daily, rivnut handrim mountng (select colour below - Note: Black hub ooly) Pink spoke / Black hub Orange spoke / black hub Note: Supply picture for custom desigos XK040 Wheel omit / supply without $ (212.00) (Specify wheel type / size / tyre) Handrim set narrow (Staodard if oo optoo selected) Handrim Positon Handrim Optons Handrim set wide XL010 Handrim aluminium hard anodised 6 tab (Lightest Opton) XL040 Handrim ttanium 6 tab (Staodard if oo optoo selected) $ 355.00 XL030 Handrim surge LT 6 tab XL050 Handrim stainless steel 6 tab $ 499.00 $ 197.00 XL020 Handrim tetra grip 6 tab XL090 Handrim remove excess mountng tab $ 318.00 $ 116.00 (Recoeoded wheo XY460 is 20 or XL100 Handrim para grip 6 tab less) (Narrow set ooly) $ 318.00 Tyre Optons XM060 Tyre Schwalbe One (Lightest opton) $ 106.00 XM010 Kenda Tyre High Pressure XM130 $ Kenda black 22.00 XM020 Tyre Schwalbe Marathon Plus $ 79.00 XM040 Tyre Shox solid airless black only $ 128.00 (24",25" ooly) Grey (Staodard if oo optoo selected) XM050 $ 32.00 Inner Tube Valve Optons Blue Red Tyre Kenda K885 mountain bike tyre (24",25" ooly) XY500 Schraeder inner tube valve (Staodard if oo optoo selected) XY490 Presta inner tube valve * Indicates items that are not part of the certfed weight of the Tiga Sub4 Page 6

CUSHION (** non certfed weight optonss XP080 $ 96.00 Upholstery cushion foam with nylon cover Cushion foam sof Cushion foam medium Cushion foam hard (CMS040) (CMS050) (9lb recoo) Cushion thickness 50 Cushion thickness 75 Cushion thickness 100 XP090 $ 79.00 Upholstery cushion cover upgrade to Air Lite XP100 $ 202.00 Upholstery cushion cover upgrade to leather Leather colour black Leather colour red Leather colour grey FRAME OPTIONS (** non certfed weight optonss XR060 Accessory welded calf strap mountng loops $ 122.00 (To locate calf strap oo froot frame) XR080 $ 838.00 Accessory frontwheel assembly (Ooly with XB010, TGAXB080, XB150) Frontwheel serial number (Ofce use ooly) ACCESSORIES (** non certfed weight optonss XP120 $ 67.00 Upholstery frame protectors neoprene zip fasten with TIGA logo (Nyloo with velcro fasteo with XR060) XR010 $ 47.00 Accessory seat pouch velcro atach (Black) XR020 Accessory large underseat storage bag (Black) $ 101.00 XR090 Accessory toolkit ** indicates optons that, when chosen, will not enable RGK to guarantee a Sub4kg product weight Page 7

XB200 Footrest with high level riser system Please indicate front footrest height: $ 160.00 XC150 $ 185.00 Castor wheel 3x1.4" aluminium centre frog legs (Silver hub aod black urethaoe tyre) OTHER (** non certfed weight optonss Footrest Castor wheels 3 and 5" XC070 Castor wheel 5x1.3" sof roll black XC100 $ 197.00 XC120 $ 185.00 XC140 $ 185.00 Castor wheel 5" pneumatc aluminium centre Castor wheel 5x1" aluminium centre frog legs (Silver hub & black urethaoe tyre) Castor wheel 5x1.4" aluminium centre frog legs (Silver hub & black urethaoe tyre) Wheel Lock Optons XD020 Wheel locks underseat scissor XD050 Wheel locks push to lock Sideguards XE030 Sideguards screw on aluminium, indicate size on page 4 $ 260.00 SBAXG020 $ 304.00 XG070 $ 180.00 Backrest Optons Backrest folding with 2 positon snap lock and angle adjust Push handle Optons Backrest with screw in push handles (N/A XG080 with XY245) $ 350.00 Backrest with fip down push handles Ant-Tip Optons XJ100 $ 402.00 XP040 Ant tp single sport Upholstery seat sling adjustable tension with straps Seat Upholstery XR050 $ 382.00 Accessory carbon fbre seat plate in lieu of seat upholstery Backrest Upholstery XP050 Upholstery backrest Airtech adjustable tension with straps XP070 $ 96.00 Upholstery upgrade to leather corners on side wings - (N/A with XG080) Leather colour black (Staodard if oot Iodicated) Backrest Upholstery Leather Optons (only with XP050) Leather colour red Leather colour grey Backrest Upholstery Sttching Optons (only with XP050) Silver Black Blue (Staodard if oot iodicated) Red Light blue Purple Backrest Upholstery Logo Optons (only with XP050) Silver Black (Staodard if oot iodicated) Blue Red Light blue Purple Backrest Accessories (only with XP050) XP110 Upholstery backrest with zip fasten pocket XP170 Upholstery with individual embroidery $ 101.00 $ 160.00 (Please provide.jpeg fle aod positooiog) ** indicates optons that, when chosen, will not enable RGK to guarantee a Sub4kg product weight Page 8

NOTES Page 9

2024 © autodocbox.com Privacy Policy | Terms of Service | Feedback