Paratransit Enquiry

ENQUIRY TYPE  Commercial Business Organisation Private
NAME:
Name: (Organisation, Business etc.)
ADDRESS:
PHONE:
FAX:
MOBILE:
EMAIL (Required):
WHEELCHAIR USER:
AGE:
CHAIR TYPE:  Manual Electric
BUDGET: (Approx.)
FUNDING BY:
NUMBER OF WHEELCHAIR POSITIONS:
ACCESS ENTRY PREFERENCE:  Rear Side
GENERAL DETAILS REQUIRED FOR QUOTATION PURPOSES
PERSONS WEIGHT: (kg)
SEATED HEIGHT: (mm)
CHAIR WEIGHT: (kg)
CHAIR LENGTH (overall): (mm)
CHAIR WIDTH (overall): (mm)
POWER CONTROLS:  Left Right
SLIDE TRANSFER:  YES NO
SELF DRIVE:  YES NO
ADDITIONAL POSTURAL SUPPORT:  YES NO
HEAD REST:  YES NO
TILT FUNCTION:  YES NO
RESTRAINT ATTACH:  YES NO
ADDITIONAL STOWAGE SPACE:
EXTRA SEATING REQUIREMENTS:
OTHER RELEVANT INFORMATION AND SPECIAL NEEDS/REQUESTS:
Quiz: 1+1=? 
Nw/XL/FW/ParatransitEnquiryForm Web Site

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