Paratransit Enquiry

    ENQUIRY TYPE CommercialBusinessOrganisationPrivate
    NAME:
    Name: (Organisation, Business etc.)
    ADDRESS:
    PHONE:
    FAX:
    MOBILE:
    EMAIL (Required):
    WHEELCHAIR USER:
    AGE:
    CHAIR TYPE: ManualElectric
    BUDGET: (Approx.)
    FUNDING BY:
    NUMBER OF WHEELCHAIR POSITIONS:
    ACCESS ENTRY PREFERENCE: RearSide
    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: LeftRight
    SLIDE TRANSFER: YESNO
    SELF DRIVE: YESNO
    ADDITIONAL POSTURAL SUPPORT: YESNO
    HEAD REST: YESNO
    TILT FUNCTION: YESNO
    RESTRAINT ATTACH: YESNO
    ADDITIONAL STOWAGE SPACE:
    EXTRA SEATING REQUIREMENTS:
    OTHER RELEVANT INFORMATION AND SPECIAL NEEDS/REQUESTS:
    Nw/XL/FW/ParatransitEnquiryForm Web Site