CUSTOM INCEPTION CUSHION ORDER FORMHCPC CODE: E2609

509 S. 22ND AVENUE | BOZEMAN, MT | PH. 800.564.9248 | FAX. 406.522.8563 | WWW.COMFORTCOMPANY.COM

Date:

Company Name/ACCT #:

Patient Name:

Patient Weight:

Patient Height:

Additional Information:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Seat Frame Width:

Seat Frame Depth:

Seat Rail Tube Size:

A - Back Width

B - Width Between Laterals

C - Width Between Hip Guides

D - Seat Width

E - Actual Seat Depth

F - Total Seat Depth

G - Back Height from Top of Cushion

H - Lateral Height from Top of Cushion

Overall Height:

1/7

CUSTOMER/PATIENT INFORMATION

SEATING SYSTEM MEASUREMENTS

NOTE:Seating system measurements do not affect any selections made through the order form.

S E A T I N G

Overall Weight:

W/C Manufacturer:

Model #: Serial #:

Order #:

D

A

B

C

E

F

G

H

1.1 SEAT/CUSHION SIZESelect desired cushion size using the sizing chart below or fill in the specific width and depth in the custom part number box.

MSR

P $

0.00

1.2 COVER MATERIAL OPTIONS

C-C-10W22D C-C-11W22D C-C-12W22D C-C-13W22D C-C-14W22D C-C-15W22D C-C-16W22D C-C-17W22D C-C-18W22D C-C-19W22D C-C-20W22D C-C-21W22D C-C-22W22D C-C-23W22D C-C-24W22D C-C-25W22D C-C-26W22D C-C-27W22D C-C-28W22D

C-C-10W21D C-C-11W21D C-C-12W21D C-C-13W21D C-C-14W21D C-C-15W21D C-C-16W21D C-C-17W21D C-C-18W21D C-C-19W21D C-C-20W21D C-C-21W21D C-C-22W21D C-C-23W21D C-C-24W21D C-C-25W21D C-C-26W21D C-C-27W21D C-C-28W21D

C-C-10W20D C-C-11W20D C-C-12W20D C-C-13W20D C-C-14W20D C-C-15W20D C-C-16W20D C-C-17W20D C-C-18W20D C-C-19W20D C-C-20W20D C-C-21W20D C-C-22W20D C-C-23W20D C-C-24W20D C-C-25W20D C-C-26W20D C-C-27W20D C-C-28W20D

C-C-10W19D C-C-11W19D C-C-12W19D C-C-13W19D C-C-14W19D C-C-15W19D C-C-16W19D C-C-17W19D C-C-18W19D C-C-19W19D C-C-20W19D C-C-21W19D C-C-22W19D C-C-23W19D C-C-24W19D C-C-25W19D C-C-26W19D C-C-27W19D C-C-28W19D

C-C-10W18D C-C-11W18D C-C-12W18D C-C-13W18D C-C-14W18D C-C-15W18D C-C-16W18D C-C-17W18D C-C-18W18D C-C-19W18D C-C-20W18D C-C-21W18D C-C-22W18D C-C-23W18D C-C-24W18D C-C-25W18D C-C-26W18D C-C-27W18D C-C-28W18D

C-C-10W17D C-C-11W17D C-C-12W17D C-C-13W17D C-C-14W17D C-C-15W17D C-C-16W17D C-C-17W17D C-C-18W17D C-C-19W17D C-C-20W17D C-C-21W17D C-C-22W17D C-C-23W17D C-C-24W17D C-C-25W17D C-C-26W17D C-C-27W17D C-C-28W17D

C-C-10W16D C-C-11W16D C-C-12W16D C-C-13W16D C-C-14W16D C-C-15W16D C-C-16W16D C-C-17W16D C-C-18W16D C-C-19W16D C-C-20W16D C-C-21W16D C-C-22W16D C-C-23W16D C-C-24W16D C-C-25W16D C-C-26W16D C-C-27W16D C-C-28W16D

C-C-10W15D C-C-11W15D C-C-12W15D C-C-13W15D C-C-14W15D C-C-15W15D C-C-16W15D C-C-17W15D C-C-18W15D C-C-19W15D C-C-20W15D C-C-21W15D C-C-22W15D C-C-23W15D C-C-24W15D C-C-25W15D C-C-26W15D C-C-27W15D C-C-28W15D

C-C-10W14D C-C-11W14D C-C-12W14D C-C-13W14D C-C-14W14D C-C-15W14D C-C-16W14D C-C-17W14D C-C-18W14D C-C-19W14D C-C-20W14D C-C-21W14D C-C-22W14D C-C-23W14D C-C-24W14D C-C-25W14D C-C-26W14D C-C-27W14D C-C-28W14D

C-C-10W13D C-C-11W13D C-C-12W13D C-C-13W13D C-C-14W13D C-C-15W13D C-C-16W13D C-C-17W13D C-C-18W13D C-C-19W13D C-C-20W13D C-C-21W13D C-C-22W13D C-C-23W13D C-C-24W13D C-C-25W13D C-C-26W13D C-C-27W13D C-C-28W13D

C-C-10W12D C-C-11W12D C-C-12W12D C-C-13W12D C-C-14W12D C-C-15W12D C-C-16W12D C-C-17W12D C-C-18W12D C-C-19W12D C-C-20W12D C-C-21W12D C-C-22W12D C-C-23W12D C-C-24W12D C-C-25W12D C-C-26W12D C-C-27W12D C-C-28W12D

C-C-10W11D C-C-11W11D C-C-12W11D C-C-13W11D C-C-14W11D C-C-15W11D C-C-16W11D C-C-17W11D C-C-18W11D C-C-19W11D C-C-20W11D C-C-21W11D C-C-22W11D C-C-23W11D C-C-24W11D C-C-25W11D C-C-26W11D C-C-27W11D C-C-28W11D

C-C-10W10D C-C-11W10D C-C-12W10D C-C-13W10D C-C-14W10D C-C-15W10D C-C-16W10D C-C-17W10D C-C-18W10D C-C-19W10D C-C-20W10D C-C-21W10D C-C-22W10D C-C-23W10D C-C-24W10D C-C-25W10D C-C-26W10D C-C-27W10D C-C-28W10D10”

12”

14”

16”

18”

20”

22”

10” 12” 14” 16” 18” 20” 22” 24” 26” 28”

MSR

P $

87.0

0

Select the desired cushion size by clicking/circling the correct size below or fill in the specific width and height measurements in the “Other Part Number Box”.

INSTRUCTIONS:

OTHER PART NUMBER BOX:If the desired size is not listed in the chart above please fill in these blank spaces with the required width and depth measurements. Then send this form to Customer Service for pricing. Fax | 406.522.8563 or customerservice@comfortcompany.com

Custom Back Part Number:

C - C - W D

Select a fabric type.

INSTRUCTIONS:

SEA

T D

EP

TH

MSRP $0.00 MSRP $66.00 MSRP $418.00

FRAME WIDTH

HCPC Code: E2609

HCPC Code: E2609

A cushion shape in Section 2.1 must be selected. The selected shape may be modified by continuing through the form.NOTE: The size and shape of the cushion must be selected in Sections 1.1 and 2.1 to determine the price of the cushion.

UP

CH

AR

GE

UP

CH

AR

GE

UP CHARGE UP CHARGE UP CHARGE

WIDTH DEPTH

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- OR -

CUSTOM CUSHION SIZE & COVER MATERIAL1

STRETCH AIR

STRETCH AIR

SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. PROVIDES NO

INCONTINENCE PROTECTION.

COMFORT TEK

COMFORT TEK

SELECTED FOR INCONTINENCE PROTECTION & AN EASILY

CLEANED SURFACE.

- OR -

Order #:

LINEARMSRP $275.00

Common Linear Specifications

2.1 CUSTOM CUSHION SHAPE

Common Linear Anti-Thrust Specs

INSTRUCTIONS:

COMMON ZERO ELEVATION CONTOUR SPECIFICATIONS: Cushion will come with:- Flat Bottom with ¼” Crosslink-1” HR Medium Lower Layer-½” HR Soft Middle Layer-1½” H Adductors-1½” H Abductor-½” Visco Soft Topper Layer

COMMON LINEAR ANTI-THRUSTSPECIFICATIONS: Cushion will come with:- Flat Bottom with ¼” Crosslink-1” HR Medium Lower Layer-½” HR Soft Middle Layer-1” High Anti-Thrust that is ½ the total depth of the cushion.-½” Visco Soft Topper Layer

COMMON ANTI-THRUST CONTOUR SPECIFICATIONS: Cushion will come with:- Flat Bottom with ¼” Crosslink-1” HR Medium Lower Layer-½” HR Soft Middle Layer-1” High Anti-Thrust that is ½ the total depth of the cushion.-1½” H Adductors-1½” H Abductors-½” Visco Soft Topper Layer

COMMON LINEARSPECIFICATIONS: Cushion will come with:- Flat Bottom with ¼” Crosslink-1” HR Medium Lower Layer-½” HR Soft Middle Layer-½” Visco Soft Topper Layer

HCPC Code: E2609 A Common Cushion Specification or Build To Specification cushion must be selected.Proceed to Section 2.2 and beyond to modify “ANY” part of the selected cushion.

Common Anti-Thrust Contour Specs

ANTI-THRUST CONTOURMSRP $350.00

ZERO ELEVATION CONTOURMSRP $350.00

Common Zero Elevation Contour Specs

- OR -

For other than the listed shapes please contact Customer Service 800.564.9248.

ANTI-THRUSTMSRP $350.00

NOTE:If linear is selected, Anti-Thrust, abduction and adduction features may NOT be selected later in the form. If these features are needed, select a different Common Specification Cushion below or use the Build To Specification option above.

NOTE:If Anti-Thrust is selected, abduction and adduction features may NOT be selected lat-er in the form. If these features are needed, select a different common cushion below or use the build to specification option above.

NOTE:If Zero Elevation Contour is selected, Anti-Thrust features may NOT be selected later in the form. If these features are needed, select a different Common Specification Cushion below or use the Build To Specification option above.

Build to Specification

NOTE:All desired build features beginning in Section 2.2 must be selected when Build to Specification is selected.

MSRP 350.00

NOTE:If Anti-Thrust Contour is selected, any of the features may be modified. If other features are needed choose the Build to Specification option above.

Proceed to Section 2.2 if selected. No common cushion specifications will be applied to the cushion if Build to Specification is selected. ?

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CUSTOM CUSHION SPECIFICATIONS2B

UIL

D T

O

SPE

CIF

ICA

TIO

NC

OM

MO

N C

USH

ION

SP

EC

IFIC

ATI

ON

S(C

CS)

Order #:

2.2 CUSHION PLATFORM

NOTE: When cushion only is selected, no platform will be included.

CUSHION ONLYMSRP $0.00

Cushion Only

REMOVABLE SOLID SEAT PAN & HARDWARE

MSRP $375.00

Removable Solid Seat & Hardware

NOTE: The solid seat pan includes a slotted aluminum pan and attach-ing hardware to accommodate 7/8” or 1” tub-ing. Hip guides can be easily attached.

RIGID INSERTMSRP $61.00

Rigid Insert Glued

Rigid Insert Not Glued

NOTE: 3/16” Plastic rigidizing board.

MOLDABLE INSERTMSRP $140.00

Moldable Insert

NOTE: Moldable aluminum enables on-site custom-ization to the contour of the cushion. ¼” Crosslink is not recommended with this insert and will not be included if a Common Specification Cushion is selected.

HCPC Code: E2609

2.3 BOTTOM STYLE

FLAT BOTTOMMSRP $0.00

Flat Bottom

FLAT BOTTOM W/RAIL CUTSMSRP $25.00

B = 1” H Rail Cut

B = 1½” H Rail Cut

B = 2” H Rail Cut

ROUND BOTTOMMSRP $25.00

Round Bottom

WEDGEMSRP $25.00

WEDGE HEIGHT

A = 1” H

A = 2” H

A = 3” H

NOTE: If a wedge bottom is selected, an HR Me-dium foam wedge is glued to the bottom of the lower layer of foam. The specified thickness of the wedge will alter the front height of the cushion and may affect the seat to floor height measurement of the chair.

NOTE: If a round bottom style is selected, a round contoured HR Medium foam is glued to the bot-tom layer of foam. ½” to 1” of addi-tional profile height will be added to the cushion.

HCPC Code: E2609

FRONT

FRONT

SIDE VIEW

FRONT

B

A

1½”

NOTE: Flat Bottom is standard if no bottom style is selected.

NOTE: If a flat bottom with rail cuts is selected, a stan-dard 1 ½” wide cut will be made and you will select how high the cut will need to be. All cuts run the entire depth of the cushion to lower overall cushion height once placed on the chair.

4/10

Multiple selections from this section are available. If nothing is selected, “Cushion Only” will be provided.

INSTRUCTIONS:

Multiple selections from this section are available. If nothing is selected, “Flat Bottom” will be provided.

INSTRUCTIONS:

Order #:

2.4 GROWTH NOTCHES(OPTIONAL)

DEPTH OF NOTCHESMSRP $25.00

SIZE

C = 1” D

C = 2” D

C = 3” D

Other

HCPC Code: E2609

COCCYX CUT OUTMSRP $0.00

Coccyx Cut Out

NOTE: Coccyx cut out will be cut in the lower layer.

2.5 COCCYX CUT OUT(OPTIONAL)HCPC Code: E2609

NOTE: If growth notches are selected, a 1¼” wide cut will be taken from each side to allow the cushion to fit between the back canes.

DEPTH OF RELIEFMSRP $25.00

SIZE

D = 1” D

D = 2” D

Other

NOTE: Hamstring relief will cause the bottom of the cushion to be more shallow than specified seat depth.

2.6HAMSTRING RELIEF(OPTIONAL)HCPC Code: E2609

DEPTH OF DISCREPANCYMSRP $75.00

L DEPTH REMOVED FROM SIDE R

E = ½” D

E = 1” D

E = 1½” D

E = 2” D

Other

The width of the cut out is half the cushion width unless “Notch for Abductor Hard-ware” is selected below.

2.7LEG LENGTH DISCREPANCY(OPTIONAL)HCPC Code: E2609

NOTCH FOR ABDUCTOR HARDWARE

Allow for Abductor Attachment

NOTE: The width of the longer side will be 1½” wider than half of the width of the cushion.

NOTE:

C

TOP VIEW

D

CENTER LINE

CENTER LINE

R L R L

FRONT

FRONT

CENTER LINE

CENTER LINE

R R LL

1¼”

The specified discrepancy reduces the depth of the cushion on the specified side.

E E

LEFT SIDE DISCREPANCY RIGHT SIDE DISCREPANCY

LEFT SIDE DISCREPANCY RIGHT SIDE DISCREPANCY

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1½”1½”

- AND/OR -

SIDE VIEW

Order #:

3.1 ANTI-THRUST (OPTIONAL)

ANTI-THRUST HEIGHT

F = ½” H

F = 1” H

F = 1 ½” H

F = 2” H

F = 2 ½” H

Other

Select height and depth for desired Anti-Thrust by filling out Sections A & B.

INSTRUCTIONS:

ANTI-THRUST DEPTHMSRP $0.00

G = 4”D G = 11 ”D

G = 5 ”D G = 12 ”D

G = 6 ”D G = 13 ”D

G = 7 ”D G = 14 ”D

G = 8 ”D G = 15 ”D

G = 9 ”D G = 16 ”D

G = 10 ”D Other

NOTE: Anti-Thrust shelf is made with an HR Medium foam that is glued to the top side of the middle foam layer.

B.A.

HCPC Code: E2609

MSRP $0.00

Select an abductor height for specific cushion contour.

INSTRUCTIONS:

3.2 ABDUCTION (OPTIONAL)HCPC Code: E2609

FRONT FRONT

Anti-Thrust Growth Kit

NOTE: Anti-Thrust growth kit will come with 3-1” deep strips, which will allow for growth of the Anti-Thrust shelf. The top layer of foam will not be glued in the seat well. A zippered pocket at rear of cushion cover is included to store the three strips.

ANTI-THRUSTG

F

ANTI-THRUST

CUSTOM CUSHION GEOMETRY3

SIDE VIEW SIDE VIEW

NOTE: Abductor insert is made of HR Medium foam and glued to the top of the middle layer of foam.

ABDUCTOR HEIGHTMSRP $0.00

No Abductor

H = ½” H

H = 1” H

H = 1 ½” H Standard

H = 2” H

H = 2 ½” H

Specify Custom Height __________

FRONT VIEW

H

RIGHT LEFT

ABDUCTOR WEDGE

Select an adductor shape for specific cushion contour in Section A, and select an Adductor height in Section B.

INSTRUCTIONS:

3.3 ADDUCTION (OPTIONAL)HCPC Code: E2609

ADDUCTOR HEIGHTMSRP $0.00

J Left Leg Adduction Right Leg Adduction K

None None

J = ½” H K = ½” H

J = 1” H K = 1” H

J = 1 ½” H Standard K = 1 ½” H Standard

J = 2” H K = 2” H

J = 2 ½” H K = 2 ½” H

Specify Custom Height _______

Specify Custom Height _______

FRONT VIEW

J

RIGHT LEFT

RIGHT ADDUCTOR

K

LEFT ADDUCTOR

B.

NOTE: Adductor insert is made of HR Medium foam and glued to the top of the middle layer of foam.

6/10

ADDUCTOR STYLEMSRP $0.00

Standard Adductor

Tapered Adductor

Omit Adductor in the Seat Well

A.

NOTE: If omit “Adductor in Seat Well” is selected, adductors will not be built into the rear half of the cushion. Tapered adductors are designed to off load the Ischial Tuberosities by loading the Greater Trochanters.

Standard

Tapered

Area Adduction Removed

FRONT

REAR

Order #:

ISCHIAL GEL INSERTMSRP $50.00

Ischial Gel Insert

LOWER LAYER (REQUIRED)

H.R. MSRP $0.00VISCO MSRP $100.00

MIDDLE LAYER(OPTIONAL)

H.R. MSRP $0.00VISCO MSRP $100.00

TOPPER LAYER(OPTIONAL)

H.R. MSRP $0.00VISCO MSRP $100.00

¼” ½” ¾” 1” 1¼” ¼” ½” ¾” 1” 1¼” ¼” ½” ¾” 1” 1¼”

5.1 ISCHIAL MODIFICATION(OPTIONAL)

NOTE: Includes four individual gel filled compartments that prevent the migration gel under the seated surface. A minimum of ¾” middle layer is required for this insert. The cushion must be at least 16” W and 16” D to use the QuadraGel® Option.

ISCHIAL QUADRAGEL® INSERTMSRP $65.00

Ischial QuadraGel® Insert

ISCHIAL SUNMATE® INSERTMSRP $45.00

1” Thick Soft Sunmate®

1” Thick X-Soft Sunmate®

NOTE: The specified type of Sunmate® helps distribute ischial and sacral pressures. A minimum of a 1” middle layer is required.

NOTE: Ischial inserts are cut into the mid layer below the topper layer.HCPC Code: E2609

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INSTRUCTIONS:

LOWER LAYER

MIDDLE LAYER

TOPPER LAYER

For other foam combinations call Customer Service 1.800.564.9248.

4.1 CUSTOM FOAM SELECTION

NOTE:

Select any combination of Lower, Middle, and Topper Layers.A minimum of one layer must be chosen, when Build to Specification is selected.

HCPC Code: E2609

Cushion contours will be placed between the two top most layers. If only one layer is selected, ¼” crosslink will be added to the bottom of the cushion.

CUSTOM FOAM SELECTION4

ISCHIAL MODIFICATIONS5

FOAM TYPE

H.R. Medium

H.R. Soft

Visco Medium

Visco Soft

Visco X-Soft

Visco XX-Soft

Crosslink (Optional)

MSR

P

$0.0

0M

SRP

$1

00.0

0

NOTE: Includes two individual gel filled compartments that prevent the migration of the gel under the seated surface. The cushion must be at least 16”W and 12”D to use the Ischial Gel Insert Option.

CROSSLINK

MSR

P

$0.0

0

CCS = Custom Cushion Specification

CCS

CCS

CCS

Order #:

A colored square must be selected if gel pack in Section 5.1 is desired.

Red Blue

Purple Green

Pink Silver

FULL LENGTH RECESSMSRP $115.00

L LEFT SIDE RIGHT SIDE R½” H ½” H

1” H 1” H

1.25” H 1.25” H

5.2 ISCHIAL RECESS (OPTIONAL)HCPC Code: E2609

INSTRUCTIONS:

Determine if a full length or rear quadrant is necessary.Select a right or left side of the desired amount of recess.

REAR QUADRANT RECESSMSRP $115.00

L LEFT SIDE RIGHT SIDE R½” H ½” H

1” H 1” H

1.25” H 1.25” H

The amount of recess must match or be thicker than the middle foam layer. A topper layer must be selected with this option.

HCPC Code: E2609

HCPC Code: E2609

6.1COLOR (OPTIONAL)

MSRP $0.00

COLOR LOCATION

6.2 PRIVACY FLAP (OPTIONAL)

Privacy Flap

MSRP $25.00

6.3ZIPPERED POUCH(OPTIONAL)

Zippered Pouch

MSRP $25.00

NOTE:

6.4EXTRA COVERS & INCONTINENCE LINER (OPTIONAL)MSRP $80.00

NOTE:Accent colors can be applied to the cushion via colored piping. If no colors are selected, no piping will be stitched onto the cushion.

NOTE:This flap connects with hook/loop between the seat and back for added privacy.

NOTE:Zippered pouch is sewn into the front of the cushion.

NOTE:Incontinence Liner pro-vides extra incontinence protection for the cush-ion. The zippered liner may be used as an extra cover when the outer cover is being washed.

Incontinence Liner

Extra Strech Air Outer Cover

Extra Comfort Tek Outer Cover

FRONT

The amount of recess must match or be thicker than the middle foam layer. A topper layer must be selected with this option.

NOTE:

FRONT

R R

L L FRONT

R

L

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CUSHION ACCESSORIES6

R

LFRONT

Order #:

COMFORT TEKSELECTED FOR INCONTINENCE

PROTECTION & AN EASILY CLEANED

SURFACE.

STRETCH AIRSELECTED FOR AIR TRANSMISSION &

HEAT DISSIPATION. PROVIDES NO

INCONTINENCE PROTECTION.

7.1 HIP GUIDES (OPTIONAL)

7.2 HIP GUIDE HARDWARE (OPTIONAL)

WIDTH ADJUSTABLE BRACKETSMSRP $100.00/ea

LEFT RIGHT

(1) Add’l L (1) Add’l R

(2) Add’l L (2) Add’l R

NOTE: Hip guide hardware will allow for width adjustability. Brackets come standard with 2 links in Section A. Each additional link adds 1” of height. Extra linkage is available for more adjustability in Section B.

HCPC Code: E0956

HCPC Code: E0956

5”

5”

RIGIDMSRP $50.00/ea

STRETCH AIRFABRIC

Add’l L L SIZE R Add’l R

3” H x 4” D

3” H x 5” D

4” H x 4” D

4” H x 6” D

4” H x 8” D

4” H x 10” D

4” H x 12” D

4” H x 14” D

4” H x 16” D

H D H D

HIP GUIDELINES & HARDWARE7

RIGID CONTOUREDfor Anti-Thrust Cushion

MSRP $50.00/ea

STRETCH AIRFABRIC

Add’l L L SIZE R Add’l R

3” H x 4” D

3” H x 5” D

4” H x 4” D

4” H x 6” D

4” H x 8” D

4” H x 10” D

4” H x 12” D

4” H x 14” D

4” H x 16” D

COMFORT TEKFABRIC

Add’l L L SIZE R Add’l R

3” H x 4” D

3” H x 5” D

4” H x 4” D

4” H x 6” D

4” H x 8” D

4” H x 10” D

4” H x 12” D

4” H x 14” D

4” H x 16” D

COMFORT TEKFABRIC

Add’l L L SIZE R Add’l R

3” H x 4” D

3” H x 5” D

4” H x 4” D

4” H x 6” D

4” H x 8” D

4” H x 10” D

4” H x 12” D

4” H x 14” D

4” H x 16” D

- OR - - OR -

A. ADDITIONAL LINKMSRP $35.00/extra link

LEFT RIGHT

(1) Add’l L (1) Add’l R

(2) Add’l L (2) Add’l R

(3) Add’l L (3) Add’l R

B.

1”

9/10

Select a left and/or right Hip Guide using “ANY” combination of both style/fabric.

INSTRUCTIONS:

Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248.

NOTE:T-Nut spacing along hip guide is 1” on center running the entire length of the pad.

Order #:

ADDITIONAL INFORMATION88.1 COMMENTS

INSTRUCTIONS:

Please reference any section or subsection of the form when commenting.

INSTRUCTIONS:

If preferred, please sketch ideas in the spaces provided below.

10/10

Section # Page # COMMENTS

Order #:

ADDITIONAL NOTES HERE: ADDITIONAL NOTES HERE: