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