Name

Email Address

Address

Phone

How did you learn about us?

Email

Additional Information that will us with your need.

Are you able to come to our office/shop Are you able to come to our office/shop Yes No

Date Of Birth

Information provided by. Information provided by. Applicant Spouse Family

Will use indoors? If so, are all your doorways wide enough? Will use indoors? If so, are all your doorways wide enough? Yes No

Do you or plan on having a handicap ramp to home? Do you or plan on having a handicap ramp to home? Yes No

Will use outdoors? If so, only use on level surfaces Will use outdoors? If so, only use on level surfaces Yes No

Do you have or will have a transport vehicle for power unit? Do you have or will have a transport vehicle for power unit? Yes No

Will you need help on and off your power unit? Will you need help on and off your power unit? Yes No

What type of power unit requested by applicant? What type of power unit requested by applicant? Power Chair Power Scooter

Current Weight Current Weight 100-15Olbs 150-200lbs 200-250lbs 250-300lbs 300+lbs

I Agree to the terms and conditions below. I Agree to the terms and conditions below. Yes, I Aggree