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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:
Nw/XL/FW/ParatransitEnquiryForm Web Site