| ENQUIRY TYPE | Commercial | Business | Organisation | Private |
| NAME: | |
| Name: (Organisation, Business etc.) | |
| ADDRESS: | |
| PHONE: | | FAX: | | MOBILE: | |
| EMAIL: | | 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) | |
| POWER CONTROLS: | Left Right | CHAIR WIDTH (overall): (mm) | |
| SLIDE TRANSFER: | YES NO | HEAD REST: | YES NO |
| SELF DRIVE: | YES NO | TILT FUNCTION: | YES NO |
| ADDITIONAL POSTURAL SUPPORT: | YES NO | RESTRAINT ATTACH: | YES NO |
| ADDITIONAL STOWAGE SPACE: | |
| EXTRA SEATING REQUIREMENTS: | |
| OTHER RELEVANT INFORMATION AND SPECIAL NEEDS/REQUESTS: |
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| Nw/XL/FW/ParatransitEnquiryForm Web Site | |