Permobil 2009 Order Forms FORMS/All_OrderForms_US.pdf · All order forms are effective July 1, ... Please indicate which armrest to mount midline below. I10428 Mount Midline Joystick

C O N T E N T S

1 . C 3 0 0 P S

2 . C 3 0 0 C o r p u s

3 . C 3 0 0 T i l t

4 . C 3 0 0 C o r p u s J r .

5 . K 3 0 0 P S J r .

6 . K 4 5 0 M X

7 . K o a l a

8 . C 3 5 0 P S

9 . C 3 5 0 C o r p u s

1 0 . C 4 0 0 C o r p u s

1 1 . C 4 0 0 C o r p u s J r .

1 2 . C 4 0 0 L o w r i d e r

1 3 . C 4 0 0 V S J r .

1 4 . C 5 0 0 C o r p u s

1 5 . C 5 0 0 L o w r i d e r

1 6 . C 5 0 0 V S S t a n d e r

1 7 . C 5 0 0 R S

1 8 . S t r e e t C o r p u s

1 9 . H D 3

2 0 . P e r m o l o c k

2 1 . X 8 5 0 C o r p u s

All order forms are effective July 1, 2009 and subject to change without notice. If you

have any questions please contact Permobil at 1.800.736.0925.

Permobil Inc 6961 Eastgate Blvd. Lebanon, TN 37090 Phone: 800-736-0925, Fax: 800-231-3556 www.permobil.com

Permobil 2009 Order Forms

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:

A) Top of Shoulders:

B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:

G) Seat Pan to Elbow:

H) Hip Width:

*I) Knee to Foot:Three column pricing on order/quote: _____

Display HCPCS Codes on order/quote: _____

Please send order/quote to fax#: (800) 231-3256

Permobil Inc.6961 Eastgate Blvd.Lebanon, TN 37090Tel: (800) 736-0925Fax: (800) 231-3256www.permobil.com

* State/Zip:

Diagnosis:

Permobil recommends that the client is evaluated bya certified rehab specialist.

Dealer Information

Client Information

Client Measurements

* Indicates a Required Field

Funding Source:

Prices effective July 1, 2009.

Client Age:

MSRP Price ListC300 PS

Chair Model and Colors

Part Number Description Price HCPCS Code

Select Options:

I10594 C300 Base PS - C300 PS0 6,595.00 K0848Price Includes: FWD C300 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, VR2 Controller, Tie-Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I103599-99-0 C300 Base PS - C300 PS1 6,595.00 K0856Price Includes: FWD C300 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, VR2 Controller, Tie-Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.


Required Items

I103499-99-0 Tri-Spoke Split Rim w/ Flat Free Drive Tire 3x8" No ChargeI103498-99-0 Tri-Spoke Split Rim w/ Pneumatic Tires - 3x8" No Charge


Required Items

I103576-99-0 C300/K300 Shroud - Onyx Black No ChargeI101381-99-0 C300/K300 Shroud - Vintage Wine No ChargeI101383-99-0 C300/K300 Shroud - Crystal Blue No ChargeI101384-99-0 C300/K300 Shroud - Metallic Charcoal Gray No ChargeI103577-99-0 C300/K300 Shroud - Platinum Silver No ChargeI101385-99-0 C300/K300 Shroud - Green Metallic No ChargeI103575-99-0 C300/K300 Shroud - Titan Blue No ChargeI103578-99-0 C300/K300 Shroud - Pop Star Pink No ChargeI103574-99-0 C300/K300 Shroud - Chili Pepper Red No Charge


Required Items

I10451 Match Hub Cap to Shroud Color No ChargeIf this is selected, the Tri-Spoke Hub Cap will be matched to the selected shroud color.

I103537-99-0 Hub Cap Platinum Silver No ChargeIf this is selected, the Tri-Spoke Hub Cap will be Platinum Silver.

Base Options


Required Items

I103779-99-0 Power Adjustable Seat Height - 8" Travel 2,395.00 E2300To assist in transfers and improve access for function.

I101994-99-0 Seat Tube Fixed No Charge


Select Options:

IM34 SLDG Batteries - Group 34, 12V 60 Amp Hours, Installed 762.00 K0108I602307-99-0 P+ PP1A Programmer - VSI, VR2 or Pilot+ Controllers 595.00I102768-99-0 Fixed Vent Shelf for C300 395.00 E1029

If selecting this part, you MUST also pick: PN I0036-7002A - ESP Unit. Fits an LP10 Sized Vent &a U1 Battery. Must be ordered with an expandable controller (ex. R-net Electronics).

I0036-7002A Enhanced Steering Perform Unit (ESP), R-net 1,150.00 K0108MUST be selected if ordering any ventilator tray (I102769-99-0, I103241-99-0, or I102768-99-0).Recommended item with switched drive inputs for improved tracking.

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Select Options:

I103564-99-0 Light Kit for C300 w/ R-net Electronics 955.00Shrouds with lights cannot be ordered with VR2 Electronics. Not compatible with CompactAdvanced Joystick (I103841-99-0).

ID51113 Programming Key for R-net - Permobil Version 435.00

Permolock


Select Options:

I104680-99-0 Permolock C3 Locking Base C300, C350, K300, K450 1,775.00Kit Includes: Permolock C3 Locking Base, owner's manual, manual release handle, and vehiclemounted release button. This item must be installed by a NMEDA Dealer. Please provide theNMEDA Dealer Name & Address where the locking Base will ship to. .NAME:_____________________________________________ . . .. ADDR:_____________________________________________

I10608 Permolock C3 Dual Locking Pin Kit - C300/K300 595.00This kit includes two spring loaded pins that will be mounted underneath the base of thewheelchair. These pins are spring loaded so they push into the wheelchair base when an obstacleis encountered. The kit also includes spacers that may be used if the Permolock C3 Base is beingmounted in a vehicle with a sloped floor. The spacers are only needed for a C300 or K300.

Joystick Options


Required Items

I10045 Cone Shaped Joystick Knob - Standard. No ChargeI100960-99-0 Chin Cup For Joystick Knob 94.00 E2324I100961-99-0 "T" Handle For Joystick Knob 139.00 E2323I100962-99-0 "Large Ball" For Joystick Knob 94.00 E2323I100963-99-0 "Softball" For Joystick Knob 127.00 E2323I100964-99-0 "Mushroom" For Joystick Knob 127.00 E2323I100965-99-0 "Stick" For Joystick Knob 127.00 E2323IPC101B Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft 127.00 E2323IPC102B Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft 127.00 E2323IPC107B Bodypoint J/S Handle Dome Shaped, Rubber 127.00 E2323


Select Options:

I10424 Fixed Joystick Mount - Right - VR2 No ChargeI10425 Fixed Joystick Mount - Left VR2 No ChargeI10412 Joystick Mount Right - Fixed, R-net Only No ChargeI10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028

Please indicate which armrest to mount midline below.I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No ChargeI10423 VR2 Basic Joystick - Standard No ChargeI103544-99-0 R-net Remote Joystick 530.00

Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.

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Select Options:

ID51040 R-net Remote Joystick w/ Toggle Switches 605.00Expandable/remote joystick with toggle switches. Used with multiple power option bases or as anupgrade for no power option or single power option bases. Must order expandable controller (PN:I10411) with this part.

ID51042 R-net Remote Joystick w/ Speed Pot & Single Toggle 730.00Expandable/remote joystick with a single toggle switch for modes/profiles & a speed pot. Used withmultiple power option bases or as an upgrade for no power option or single power option bases.Must order expandable controller (PN: I10411) with this part.

ID51153 R-net Remote Color Screen Joystick w/ Mono Jacks 835.00Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.

ID51190 R-net Remote Color JS w/ Speed Pot & Single Toggle 875.00Must order expandable controller (PN: I10411) with this part.

ID51149 R-net Remote Color Screen JS w/ Toggle Switches 875.00Must order expandable controller (PN: I10411) with this part.

I10411 Expandable Controller - R-net 525.00 E2377Must be ordered with the expandable/remote joysticks (PN: I10410, I103544-99-0, ID51040,ID51108, ID51042, and I103814-99-0).

I10513 Harness for Expandable Controller 445.00 E2313Must be ordered with any Expandable Controller (I10411 or I10450)

ID50882 Attendant Control for R-net Control System Only 1,084.00 E2331Not available with VR2 Controllers.

ID51111 R-net BT Mouse Module 795.00The R-net BT Mouse Module allows for mouse control through a standard R-net Joystick or othertype of input device (ex: Mini Joystick w/ Omni). It is only usable as a mouse on a computer. ItCANNOT be paired to work with other Bluetooth devices such as cell phones, wireless headsets,etc. This kit includes: an R-net BT Mouse Module, a 1.5m R-net Bus Cable, and a USB StyleBluetooth Adapter for the user's computer. Note: The Bluetooth Adapter may not work with allcomputers.

Seating System


Required Items

I10281 PS Seating System Only - C300/C350 No ChargeIncludes: Seat Frame, Fixed Back Frame, Fixed Legrests and Footplates, Fixed Arm Supports andStandard Armrest Pads. Weight Limit 300 lbs.

I10142 PS Seating System With 45 Degree CG Power Tilt 4,763.00 E1002Price Includes: Seat Frame, All Seat Sizes, Angle Adjustable Back Canes, Height AdjustableArmrests, Standard Armrest Pads, Swing Away Legrests and Footplates. Weight Limit 300lbs.

Seating System Options


Select Options:

I10289 Single Seat Function Control Switch - LiberT No ChargeThis device is a single toggle switch used to control only one seat function. If control of the seatfunction through the drive control is needed, then the drive electronics must be upgraded to Pilot+or R-net Electronics, and a Single Seat Function Control Kit (Part Number I10129), must beselected.

I10419 Single Seat Function Control Kit for R-net 1,478.00 E2310For operation of a single seat function through the wheelchair electronics via the drive controland/or ICS Switchbox. Order with R-net Controller or remote joystick options. Please indicatebelow if you want push buttons or toggles on the Seat Function Control Kit.

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Select Options:

I10585 Multiple Seat Function Control Kit for R-net 2,875.00 E2311MUST be selected if ordering two or more seat functions. This device is used to operate two ormore seat functions through the wheelchair electronics via the drive control and/or ICS switch box.Order with R-net electronics or remote joystick options. Please indicate below if you want pushbuttons or toggles on the Seat Function Control Kit.

I102798-99-0 Push Buttons on Seat Function Control Kit No ChargeI102799-99-0 Toggle Switches on Seat Function Control Kit 245.00I103469-99-0 Mount ICS Switchbox onto R-net Joystick Bracket No Charge

ICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item isselected, the ICS Switchbox will swing away with the Joystick Module.

I103470-99-0 Mount ICS Switchbox on Backrest 125.00I104196-99-0 ICS Alternative Switchbox for R-net Electronics 985.00 K0108

Not available with VR2 Electronics. Seat function interface box which accommodates up to 8momentary switches. Provides an additional method to accessing the seat functions. You must stillorder the Multiple Seat Function Control Kit if ordering this part. 1/8" mini-mono switches notincluded.

I104746-99-0 Remote Stop System - R-net, Pilot+ 985.00Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on thewheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be usedtogether. Custom charge may be required if ordering with a low backrest height or a pediatricwheelchair. If ordering Remote Stop System with a K450, push handles must also be selected.

I104769-99-0 Remote Stop System VSI, VR2, Safegate 985.00Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on thewheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be usedtogether. Custom charge may be required if ordering with a low backrest height or a pediatricwheelchair. If ordering Remote Stop System with a K450, push handles must also be selected.

Backrest Options


Required Items

I10144 Sling Upholstery Back Support - Standard No ChargeWidth will be the same as seat width.

I10145 Curved Metal Back Support 22" High 410.00I10146 Curved Metal Back Support 22" High - No Charge No Charge

No charge if ordering tilt.I10454 Omit Backrest No Charge


Required Items

I10148 Angle Adjustable Back Canes 127.00Angle adjustable from 85 to 115 degrees.

I10149 Angle Adjustable Back Canes - No Charge No ChargeNo charge if ordering tilt.

Seat Sizing


Required Items

I10150A Seat Width 16" No ChargeI10151A Seat Width 18" No ChargeI10219A Seat Width 20" No ChargeI10220A Seat Width 22" No Charge


Required Items

Page 5 of 9Rev 2009-4 8/24/2009 3:02:15PM



Required Items

I10156 Seat Depth 16" No ChargeI10157 Seat Depth 17" No ChargeI10158 Seat Depth 18" No ChargeI10159 Seat Depth 19" No ChargeI10221 Seat Depth 20" No ChargeI10222 Seat Depth 21" No ChargeI10223 Seat Depth 22" No Charge

Armrest Options


Required Items

I10164 Fixed Height Armrest Assembly PS No ChargeFlips back for transfers.

I10163 Height Adjustable Armrest Assembly PS 284.00 E0973Adjustable in height, with a flip-back design.

I10230 Height Adjustable Armrest Assembly PS - No Charge No ChargeAdjustable in height, with a flip-back design. No charge if ordering power tilt.


Select Options:

I10290 PS Armrest Pads - 10.5"L x 2"W (Pair) No ChargeI10291 PS Armrest Pads - 14"L x 2"W (Pair) No ChargeI10292 Waterfall Armrest Pad for PS - 13.5"L x 3"W (Pair) 79.00I10168 Omit Armrest Pads No ChargeI10166 Corpus Armrest Pad Adapter Brackets 50.00

Must be picked if ordering Corpus armrest pads.I10208 Corpus Armrest Pad 4"x10" Left Leatherette 92.00I10209 Corpus Armrest Pad 4"x12" Left Leatherette 92.00I10210 Corpus Armrest Pad 4"x14" Left Leatherette 92.00I10211 Corpus Armrest Pad 4"x16" Left Leatherette 92.00I10212 Corpus Armrest Pad 4"x10" Right Leatherette 92.00I10213 Corpus Armrest Pad 4"x12" Right Leatherette 92.00I10214 Corpus Armrest Pad 4"x14" Right Leatherette 92.00I10215 Corpus Armrest Pad 4"x16" Right Leatherette 92.00I10169 Armrest Side Support Right Inner 142.00

Will limit the armrest from flipping back. For Corpus Armrest Pads only.I10170 Armrest Side Support Left Inner 142.00

Will limit the armrests from flipping back. For Corpus Armrest Pads only.I101261-99-0 Armrest Side Support Right Outer 142.00

For Corpus Armrest Pads only.I101262-99-0 Armrest Side Support Left Outer 142.00

For Corpus Armrest Pads only.

Legrest Options


Required Items

I10172 70 Degree Swing Away Legrests (Pair) 199.00I10231 70 Degree Swing Away Legrests (Pair) No Charge

No charge if ordering Power Tilt.

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Required Items

I10316 Aeron Legrest Assembly for PS Seat 315.0090° Legrest Hanger with Manual Adjustment Legrest Elevation. Price includes Corpus Style, AngleAdjustable, Two Piece Footplates.


Required Items

I10173 Footplates (Pair), Standard Small No ChargeI10174 Footplates (Pair), Standard Large No Charge

Not available with 16" seat width.I10175 Small Footplates, Multi - Axis Adjustable, Aluminum 195.00 K0108I10176 Large Footplates, Multi - Axis Adjustable, Aluminum 195.00 K0108

Cannot be ordered with 16" or 18" seat widths.


Select Options:

I10177 Heel Loops 90.00 E0951Not available with Aeron Legrest Assembly. (I10316).

I10197 Calf Supports Leatherette No ChargeNot available with lower leg lengths of 10" or less.

I10104 Calf Supports for Aeron Legrest Assembly - PS No Charge E0995Not available with lower leg lengths of 10" or less. Can be ordered only with Aeron LegrestAssembly for PS Seat (PN: I10316).

Accessories


Select Options:

I10401 Bodypoint Non-Padded Hip Belt, PS - Medium No ChargeI10406 Bodypoint Padded Hip Belt PS (C300) - Medium 124.00 K0108I10403 Bodypoint Non-Padded Hip Belt, PS - Large 93.00 K0108I10409 Bodypoint Padded Hip Belt PS - Large 155.00 K0108I10199 Headrest-Removable Leatherette 263.00 E0955

Must also select PN I10552.I103460-99-0 UT Ergo Headrest w/ Black Fabric Cover 292.00 E0955

Must also select PN I10552.I10180 Universal Headrest Adapter 197.00 K0108

Will be sent as part if ordering sling back upholstery.I10552 Adj Removable - Headrest Hardware (1 Each) 212.00 E1028I102059-99-0 Medical Necessities Bag 265.00

Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00I10179 Back Pack Clips Carabiner Style 75.00

Will be sent as part if ordering sling back upholstery.I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950

Must also select PN I10556.I10556 Adj Removable - Tray Hardware (1 Each) 212.00 E1028I101964-99-0 Oxygen Holder for PS or Corpus Seat 224.00

Cannot be ordered with a Corpus Tubular Backrest. (I10111 or I10112). Custom charge may beapplied if ordering in combination with accessories such as medical necessities bags, attendantcontrols, push handles, back pack clips, etc. This item is mounted to the Ergonomic Backrest.

I101956-99-0 Crutch Holder for PS or Corpus Seat 224.00Cannot be ordered with a Corpus Tubular Backrest. (I10111 or I10112). Accessories such asmedical necessities bags and push handles may need to be sent as parts if ordering a crutchholder. This item is mounted to the ergonomic backrest.

Page 7 of 9Rev 2009-4 8/24/2009 3:02:15PM


Alternative Drive Systems


Required Items

R-net Alternative Drive Input DevicesR-net Alternative Drive Input Devices take the place of, or may be used in addition to, the standardR-net Joystick. They are only usable on wheelchairs that have R-net electronics. You MUSTselect one of each of the following items: (1) Input Device, (2) Expandable Controller, (3)Adjustable/Removable Alt Drive Hardware, AND (4) Omni or Input Module.

(1) INPUT DEVICES FOR ALTERNATIVE DRIVE CONTROLI10558 Gimble Joystick set up for Armrest Mount 1,388.00 E2373I10559 Gimble Joystick set up for Midline Mount 1,388.00 E2373I10560 Gimble Joystick set up for Swing Away Chin Boom 1,388.00 E2373

Custom charge may be applied if ordering lower backrest heights.I10561 Gimble Joystick w/ Haims Harness - Small 1,555.00 E2373

For neck width up to 5".I10562 Gimble Joystick w/ Haims Harness - Large 1,555.00 E2373

For neck width up to 7".I10563 Gimble Joystick w/ Power Swing Away Chin Boom 5,174.00 E2399

Custom charge may be applied if ordering smaller backrest sizes and heights.I10564 Mini Joystick set up for Armrest Mount 2,035.00 E2312I10565 Mini Joystick set up for Midline Mount 2,035.00 E2312I10566 Mini Joystick set up for Swing Away Chin Boom 2,035.00 E2312

Custom charge may be applied if ordering lower backrest heights.I10567 Mini Joystick w/ Haims Harness - Small 2,135.00 E2312

For neck width up to 5".I10568 Mini Joystick w/ Haims Harness - Large 2,135.00 E2312

For neck width up to 7".I10569 Mini Joystick w/ Power Swing Away Chin Boom 5,174.00 E2399

Custom charge may be applied if ordering lower backrest heights.I1821750 Tablet Control Pad 3,614.00 E2328

The Tablet Control is a unique drive input which allows a user to control a power wheelchair in avery similar manner to a mouse being controlled by a touchpad on a laptop computer. Thedimensions of the Tablet Control Pad are: 12"W x 9.5"D x 1.5"H. Kit also includes: Buddy ButtonSwitch, and Tablet Control Mounting Bracket.

I10570 Head Array - Adult 5 Switch HDR-A5 3,614.00 E2330I10571 Head Array - Adult 3 Switch HDR-A4 3,614.00 E2330

Requires Omni Control Module. Cannot use this part with an Input Module.I10572 Head Array - Pediatric 5 Switch HDR-C5-RR 3,614.00 E2330I10573 Sip & Puff System 1,409.00 E2325

Requires Omni Control Module. Cannot use this part with an Input Module.I10574 Sip & Puff System with Fiber Optic Opti-Stop 1,929.00 E2325,E2326

Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tubekit.


Select Options:

I10076 Right Side Mount For Joystick No ChargeI10077 Left Side Mount For Joystick No ChargeI10074 Right Side Mount For Omni No ChargeI10075 Left Side Mount For Omni No ChargeI10078 Mount Seat Control Panel on Right No ChargeI10079 Mount Seat Control Panel on Left No ChargeI10080 Mount Seat Control Panel on Backrest No Charge

Alt Drive Systems Setup

Page 8 of 9Rev 2009-4 8/24/2009 3:02:15PM



Required Items

(2) EXPANDABLE CONTROLLER (REQUIRED)I10576 Expandable Controller - Alternative Drive 525.00 E2377


Required Items

(3) ADJUSTABLE REMOVABLE HARDWARE (REQUIRED)I10577 Adjustable Removable Hardware - Alt Drive 212.00 E1028


Required Items

(4) OMNI OR INPUT MODULE (REQUIRED)Cannot select Input Module with Sip-n-Puff Input Devices (PN I10573 or I10574).

ID51154IR Omni Control Module for R-net w/ Infrared 1,470.00Please specify which type of alternative drive input you will be using if not ordering the input devicefrom Permobil. Input Device: ___________________________

I10581 Input Module (IOM) for R-net Control System 995.00 E2351This device allows a proportional or switched drive input to be connected to an R-net ControlSystem without the use of an Omni. It must be ordered in conjunction with an R-net RemoteJoystick. It does NOT support any of the following input devices: Sip-n-Puff, 3-Switch Head Arrayor RIM control.

Alt Drive Accessories


Select Options:

IMICROSWITCH Microlite Switch 148.00IBUDDYBUTTON Buddy Button 111.00 K0108I5808 Mini Cup Switch 108.00IZTS-P Proximity Switch 515.00IMINIJOY5SW Mini Joystick 5 Switch OC 593.00I5018 Wafer Board w/5 Switches 497.00

Chair Order Policy:You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at 1-800-736-0925. Theorder cannot be processed without the following:

-A client name or code, the client’s measurements, the client’s weight-The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, Inc. is notresponsible for configuration or size discrepancies resulting from customer errors on the order form.

-Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully.-Once the order is shipped, any changes are subject to the returns policy and may be prohibited.

Order Acknowledgement:

I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for thepurchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete andaccurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returnspolicy and may carry additional charges.

Signed:

Printed Name:

Title:

Date:

NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if orderedwith the wheelchair. Any parts ordered for service or future alterations will carry different pricing and warranty. MID PROFILE®Cushion is a registered trademark of the The ROHO Group.The HCPCS codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes doesnot ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer.

Page 9 of 9Rev 2009-4 8/24/2009 3:02:15PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC300 Corpus



Select Options:

I10592 C300 Base Corpus R-net - C300 PS0 6,595.00 K0848Price Includes: FWD C300 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Controller, Tie-Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I10593 C300 Corpus R-net - C300 PS1 6,595.00 K0856Price Includes: FWD C300 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I103260-99-0 C300 Base Corpus R-net - C300 PS2 6,595.00 K0861Price Includes: FWD C300 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Anti-Tippers, Charger, FlatFree Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items



Required Items



Base Options


Required Items




Select Options:

IM34 SLDG Batteries - Group 34, 12V 60 Amp Hours, Installed 762.00 K0108I102768-99-0 Fixed Vent Shelf for C300 395.00 E1029


Page 2 of 12Rev 2009-4 8/24/2009 2:59:49PM



Select Options:

I102769-99-0 Articulating Vent Tray for C300 1,295.00 E1030If selecting this part, you MUST also pick: PN I0036-7002A - ESP Unit. Fits an LP10 Sized Ventand a Group 34 Battery. Cannot be ordered with any backrest height less than 26.5", a tubularback, or a 13" seat depth. Customization may be required if ordered with any of the following itemsCo-Pilot, any standard attendant control, push handles, or an oxygen holder. Only available withexpandable controllers (R-net Electronics.)




Permolock


Select Options:



Joystick Options


Required Items



Select Options:

I10412 Joystick Mount Right - Fixed, R-net Only No ChargeI10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028

Page 3 of 12Rev 2009-4 8/24/2009 2:59:49PM



Select Options:

I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028Please indicate which armrest to mount midline below.

I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No ChargeI10410 R-net Remote Joystick - No Charge No Charge

Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.I103544-99-0 R-net Remote Joystick 530.00









I104003-99-0 Co-Pilot Attendant Control, Corpus R-net 4,175.00 E2331Custom charge may apply if ordering a Corpus Tubular Backrest OR a backrest height of 21" orLower. Not available with VR2 Controllers.



I10582 Output Module (IOM) for R-net Control System 995.00 E2351This allows a user to control an external device (ex: Communication Device, ECU, Door Opener,etc.) through the drive input (JSM, Head Array, etc.). One output module is required for eachseparate external device to be controlled. Up to three output modules can be installed on onewheelchair.

Seating System


Required Items

The Seating Systems Listed Below Include:Corpus Seat Frame, Solid Backrest (Standard Size) with Manual Adjustable Recline Angle, HeightAdjustable Armrest Assembly, Solid Seat Pan (17"W x 18"D), Legrest Assembly with ManualAdjustable Elevation. Weight Limit 265 lbs.

I10239 Corpus Seat without Power Tilt or Power Recline 5,595.00 K0108I103525-99-0 Corpus Seat w/ 45° CG Pwr Tilt & Manual Recline 6,195.00 E1002I103528-99-0 Corpus Seat w/ 150° Power Recline 6,650.00 E1004

Page 4 of 12Rev 2009-4 8/24/2009 2:59:49PM



Required Items

I10417 Corpus Seat w/ 45° CG Pwr Tilt & 150° Pwr Recline 10,195.00 E1007



Select Options:

I10418 Single Seat Function Control Switch for R-net No ChargePlease choose either Push Buttons or Toggle Switches below.





I103471-99-0 Mount ICS Switchbox to End of Arm Pad - Corpus No ChargeICS Switchbox will be mounted to the end of the armrest pad. If this item is selected, the ICSSwitchbox will NOT swing away with the Joystick Module. Please indicate below if you would like itmounted onto the left or right arm pad.

Mount ICS Switchbox on Left Armpad _________Mount ICS Switchbox on Right Armpad _________




Backrest Options


Required Items

BACKREST HEIGHT NOTE:Backrest heights are measured from the seat pan to the top of the backrest shell with the backrestset at 90°.

I101853-99-0 Ergo Back Fixed 14" W x 21" H - Leatherette 837.00 E2620I101863-99-0 Ergo Back Fixed 14"W x 26.5" High - Leatherette 837.00 E2620I101854-99-0 Ergo Back Sliding 16"W x 21"H - Leatherette 837.00 E2620I101861-99-0 Ergo Back Sliding 16"W x 26.5" H - Leatherette 837.00 E2620I101855-99-0 Ergo Back Sliding 18"W x 21"H - Leatherette 837.00 E2620I101862-99-0 Ergo Back Sliding 18"W x 26.5"H - Leatherette 837.00 E2620I305510-00-90-0 Ergo Back Fixed Tall 16"W x 29.5"H - Leatherette 837.00 E2620

Page 5 of 12Rev 2009-4 8/24/2009 2:59:49PM



Required Items

I10455 Ergo Back Fixed 14" W x 21" H - Black Mesh 859.00 E2620I10456 Ergo Back Fixed 14"W x 26.5" High - Black Mesh 859.00 E2620I10457 Ergo Back Sliding 16"W x 21"H - Black Mesh 859.00 E2620I10458 Ergo Back Sliding 16"W x 26.5" H - Black Mesh 859.00 E2620I10459 Ergo Back Sliding 18"W x 21"H - Black Mesh 859.00 E2620I10460 Ergo Back Sliding 18"W x 26.5"H - Black Mesh 859.00 E2620I10004 Rectangular Backrest 16"W - Plastic, Fixed 1,119.00

Choose backrest height from seat pan: 19"-29" ___"I10005 Rectangular Back 18"W - Metal Fixed 1,307.00

Choose backrest height from seat pan: 19"-29" ___"I10240 Solid Back 16"W X 21"H No Charge

Standard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.I10130 Solid Back 16"W x 26.5"H No Charge

Standard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.I10241 Solid Back 18"W x 21"H No Charge


Standard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.I10111 Tubular Backrest Frame Corpus, 16" Wide 357.00

Backrest canes to mount aftermarket backrest systems. For tilt only systems. Measurementbetween the armrests is 17.5". Seat pan to top of canes is 22".

I10112 Tubular Backrest Frame Corpus, 18" Wide 357.00Backrest canes to mount aftermarket backrest systems. For tilt only systems. Measurementbetween the armrests is 19.5". Seat pan to top of canes is 22"


Select Options:

I10014 Custom Backrest Height ______" 625.00Backrest height measured from seat pan and cannot be lower than 19". Price in addition to abovebackrest.

I100972-99-0 Split Backrest 535.00Split Backrest 8" from top to allow for transfers and/or transportation. This modification cannot bemade on back heights lower than 26.5". Must select either PN: I10429 or I10430 below.

I10429 Split Backrest Cushion No ChargeI10430 Do NOT Split Backrest Cushion No ChargeI10284 Flat Backrest Cushion for Ergo Back - Leatherette 89.00

This style of cushion is ONLY available in Leatherette. Recommended cushion when orderinglateral supports. Lateral wedges will be omitted if ordering this part.

I10318 ROHO Backrest Cushion For Ergo Back 625.00Price Includes: ROHO MID PROFILE Backrest Cushion which will be matched to fit the ErgonomicBackrest that you select. Approximate height of MID PROFILE cells is 3" in their inflated state.Also includes a Mesh Cover for the ROHO Backrest Cushion, Hand Pump, and Patch Kit. This willNOT fit these part numbers: (I10004, I10005, I10111, I10112, I305510-00-90-0). Please indicatebelow if you would like to OMIT the Ergo Back Cushion.

I10319 ROHO Backrest Cushion For Ergo Back - Notched 625.00Recommended ROHO cushion when ordering Lateral Trunk Supports. Please indicate below ifyou would like to OMIT the Ergo Back Cushion.

I10320 Omit Ergonomic Backrest Cushion No Charge

Seat Sizing


Required Items

I100684-99-0 Corpus Seat 17"W x 16"D No ChargeI100689-99-0 Corpus Seat 17"W x 18"D No Charge

Page 6 of 12Rev 2009-4 8/24/2009 2:59:49PM



Required Items

I100695-99-0 Corpus Seat 17"W x 20"D No ChargeI100720-99-0 Corpus Seat 17"W x 22"D No ChargeI100690-99-0 Corpus Seat 19"W x 18"D No ChargeI100696-99-0 Corpus Seat 19"W x 20"D No ChargeI100721-99-0 Corpus Seat 19"W x 22"D No ChargeI10007 Special Seat Size 21"W x 18"D No ChargeI10008 Special Seat Size 21"W x 20"D No ChargeI10009 Special Seat Size 21"W x 22"D No Charge


Select Options:

I10038 Ergonomic Seat Cushion Leatherette 475.00 E2601,E2602Not available with seat widths less than 16" or seat depths less than 14".

I10461 Ergonomic Seat Cushion - Black Mesh 485.00 E2601Not available with seat widths less than 16" or seat depths less than 14".

Armrest Options


Required Items

I103339-99-0 4"x10" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103341-99-0 4"x12" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103343-99-0 4"x14" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103345-99-0 4"x16" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103331-99-0 4"x10" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103333-99-0 4"x12" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103335-99-0 4"x14" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103337-99-0 4"x16" Corpus Arm Right - Dual Taper, Black Fabric No Charge


Required Items

I103338-99-0 4"x10" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103340-99-0 4"x12" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103342-99-0 4"x14" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103344-99-0 4"x16" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103330-99-0 4"x10" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103332-99-0 4"x12" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103334-99-0 4"x14" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103336-99-0 4"x16" Corpus Arm Left - Dual Taper, Black Fabric No Charge


Select Options:

I10137 Height Adjustable Armrest Assembly 284.00 E0973I10016 Height Adjustable Armrest Assembly - No Charge No Charge

No charge with power tilt and/or recline.I101003-99-0 Armrest Mount High No Charge

Range of adjustment in high position is 11" - 13.5" measured from the seat pan to the top of thearmrest pad.

I101002-99-0 Armrest Mount Low (High Position Standard) No ChargeRange of adjustment in low position is 9" - 11.5" measured from the seat pan to the top of thearmrest pad.

I304968-99-0 Corpus Armbar for 18" Btw the Arms - Installed 265.00I10001 Corpus Armbar for 20" Btw the Arms - Installed 295.00

Page 7 of 12Rev 2009-4 8/24/2009 2:59:49PM



Select Options:

I100523-99-0 Armrest Height Ext (+2") 125.00IARMADAP1" Arm Trough Adaptor 1" Pair 274.00

For aftermarket arm troughs. Please indicate below if they should be installed or on chair sent asparts.

IARMADAP7/8" Arm Trough Adaptor 7/8" Pair 274.00For aftermarket arm troughs. Please indicate below if they should be installed on chair or sent asparts.

Install Arm Trough Adapters: _____Send Arm Trough Adapters as Parts: _____

I100671-99-0 Armrest Pouch-Right 190.00I100672-99-0 Armrest Pouch-Left 190.00I101261-99-0 Armrest Side Support Right Outer 142.00


For Corpus Armrest Pads only.I101263-99-0 Armrest Side Support Right Inner 142.00

Recommend 2" wider width between the armrest to ensure armrests will flip-up.I101264-99-0 Armrest Side Support Left Inner 142.00

Recommend 2" wider width between the armrest to ensure armrests will flip-up.I101510-99-0 Armrest Supports HD 486.00

Cannot be ordered with 175 degree power recline seating systems. (I10482, I10485, I10488).I10285 Mount Corpus Armrest Pads On Inside of Bracket No Charge

Used to achieve 14"W between the arm measurement when ordering a 14"W Backrest.

Legrest Options


Required Items

I102206-99-0 Manual Adjustment Legrest Elevation No ChargeI103534-99-0 Power Articulating Center Mount Elevating Legrest 2,495.00 K0108


Select Options:

I103055-99-0 UT Calf Support Kit (B) w Mesh Cover & Adj Hardware No Charge3.5"W x 4.5"T Pad. Recommended pad to be used with lower leg lengths of 12" or less.

I102982-99-0 UT Calf Support Kit (J) w Mesh Cover & Adj Hardware No Charge5"W x 6.5"T Pad.

I102978-99-0 UT Calf Support Kit (H) w Mesh Cover & Adj Hardware 312.00 E10287"W x 7"T Curved Pad.

I100561-99-0 Legrest Assm. 1pc Footplate (Complete) 395.00I101276-99-0 Legrest Assm. 2pc Footplates (Complete) No ChargeI10024 Leg Length Ext Kit (pair) 16-21" From Seat Pan 275.00

Standard length is 11" - 16" from seat pan to footplate. Set legs at ______" from top of seat pan tofootplate.

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium 113.00 K0108I10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108

Page 8 of 12Rev 2009-4 8/24/2009 2:59:49PM



Select Options:

I100519-99-0 Positioning Belt Retractable 235.00 K0108I100600-99-0 Positioning Belt Retractable Long 255.00 K0108I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955

Must also select PN I10552. This part consists of a leatherette headrest pad (10"W x 5"T) with a10"L slotted, curved mounting bracket.

I103460-99-0 UT Ergo Headrest w/ Black Fabric Cover 292.00 E0955Must also select PN I10552.

I1823249 UT Lateral Adjustment Bar for UniTrack Headrest 55.00Allows for approximately 4" of lateral adjustment to the UT Ergo Headrest either right or left. NOTE:Due to the width of this item (approx 9"), it may be necessary to send other items such as backpack clips unmounted. Custom charge may apply with lower back heights.

IHEADADAPTER Universal Headrest Adapter 197.00 K0108For aftermarket headrests.

I10552 Adj Removable - Headrest Hardware (1 Each) 212.00 E1028I103070-99-0 UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each) 125.00 E1020

7"W x 7"T Curved Pad. Must also select PN I10553.I103071-99-0 UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) 125.00 E1020

8"W x 8"T Flat Pad. Must also select PN I10553.I10553 Adj Removable - Amp Support Hardware (1 Each) 212.00 E1028

Please indicate if you would like the amputation support mounted on the right or left side of the seatframe: Mount Amp Suppt on Right: ___________ Mount Amp Suppt on Left: ___________

I103077-99-0 UT Hip Suppt (B) w/ Mesh Cover - Low (Pair) 225.00 E09564.5"W x 3.5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.

I103079-99-0 UT Hip Suppt (A) w/ Mesh Cover - Low (Pair) 225.00 E09566"W x 5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.

I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) 225.00 E09566.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I103095-99-0 UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) 225.00 E09568"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I102977-99-0 UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) 225.00 E095612"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I305266-28-90-0 Lateral Supports Std. Leatherette-ErgoBack Only 246.00 E0956

Must also select PN I10551.I100521-99-0 Swing Away Trunk Supports Leatherette-For Ergo Back 250.00 E0956

Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I100978-99-0 Abductor Kit - Leatherette 306.00 E0957

Must also select PN I10555.I10555 Adj Removable - Abductor Hardware (1 Each) 212.00 E1028I10015 Knee Block Assembly Corpus 630.00 K0108I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I100975-99-0 Push Handles for Ergo Backrest 339.00

Order with Ergonomic or Rectangular Backs. Custom charge may apply if ordering push handleswith an articulating vent tray.

I307103-00-0 Push Handles for Tubular Backrest 337.00Order with Corpus Tubular Backs (PN: I10111 & I10112).

I101473-99-0 Back Pack Clips Carabiner Style 75.00I102059-99-0 Medical Necessities Bag 265.00

Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950

Must also select PN I10556.I100575-99-0 Upper Extremity Support Angle Adjustable. 14" W 267.00 E0950

Must also select PN I10556.

Page 9 of 12Rev 2009-4 8/24/2009 2:59:49PM



Select Options:

I100576-99-0 Upper Extremity Support Angle Adjustable. 16" W 279.00 E0950Must also select PN I10556.


I100571-99-0 Upper Extremity Support Joystick Cutout 16" W 322.00 E0950Must also select PN I10556.


I100573-99-0 Upper Extremity Support Mid Joystick Cutout 16"W 395.00 E0950Must also select PN I10556.


I103426-99-0 Upper Extremity Support Angle Adjust - UniTrack 296.00 E0950Side mounted tray that attaches to the UniTrack Accessory Rail. Dimensions are: 19.5"W x 13"D.Can only be ordered with chairs that offer the UniTrack System. Must also select PN I10556.

I10556 Adj Removable - Tray Hardware (1 Each) 212.00 E1028I101964-99-0 Oxygen Holder for PS or Corpus Seat 224.00





Required Items










Custom charge may be applied if ordering lower backrest heights.

Page 10 of 12Rev 2009-4 8/24/2009 2:59:49PM



Required Items

I1821750 Tablet Control Pad 3,614.00 E2328The Tablet Control is a unique drive input which allows a user to control a power wheelchair in avery similar manner to a mouse being controlled by a touchpad on a laptop computer. Thedimensions of the Tablet Control Pad are: 12"W x 9.5"D x 1.5"H. Kit also includes: Buddy ButtonSwitch, and Tablet Control Mounting Bracket.






Select Options:




Required Items



Required Items



Required Items






Select Options:

IMICROSWITCH Microlite Switch 148.00

Page 11 of 12Rev 2009-4 8/24/2009 2:59:49PM



Select Options:

IBUDDYBUTTON Buddy Button 111.00 K0108I5808 Mini Cup Switch 108.00IZTS-P Proximity Switch 515.00IMINIJOY5SW Mini Joystick 5 Switch OC 593.00I5018 Wafer Board w/5 Switches 497.00






Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 2:59:49PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC300 Corpus Tilt



Required Items

I103615-99-0 C300 Base Corpus VR2 - C300 PS1 6,595.00 K0856Price Includes: FWD C300 Power Base Set Up Power Tilt, Shock Absorbing Suspension System,VR2 Advanced Controller, Tie Down Hardware for Strap Systems, Anti-Tippers, Charger, Tri-SpokeSplit Rim with Flat Free Drive Tires, Platinum Silver Hubcaps, and Standard Positioning Belt.Substitution of items from other order forms is not allowed on this configuration.


Required Items

I103576-99-0 C300/K300 Shroud - Onyx Black No ChargeI101383-99-0 C300/K300 Shroud - Crystal Blue No Charge

Base Options


Required Items

IM34 SLDG - REQD Batteries - Group 34, 12V 60 Amp Hrs, Installed 695.00 K0108Batteries MUST be selected with this configuration


Select Options:

I101995-99-0 Fixed Seat Tube for Tilt No ChargeI101997-99-0 Power Adjustable Seat Height - 8" Travel 2,395.00 E2300

To assist in transfers and improve access for function.I602307-99-0 P+ PP1A Programmer - VSI, VR2 or Pilot+ Controllers 595.00

Joystick Options


Required Items

I103613-99-0 VR2 Advanced Joystick No Charge Non expandable joystick capable of controlling tilt and a seat elevator through the joystick.


Required Items



Required Items

I10468 Joystick Mount Right - Fixed, VR2 No ChargeI10469 Joystick Mount Left - Fixed, VR2 No ChargeI10470 Joystick Mount Right - Swing Away, VR2 292.00 E1028I10471 Joystick Mount Left - Swing Away, VR2 292.00 E1028

Page 2 of 6Rev 2009-4 8/24/2009 3:00:48PM



Required Items

I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028

Seating System


Required Items

This Configuration of the Corpus Seat Includes:Corpus Seat Frame, 45° CG Power Tilt, Manual Recline, Manual Elevating Non-ArticulatingLegrests, 14"L Leatherette Armrests, Height Adjustable Armrest Assembly with Arms Mounted inthe Tall Position, and Two Piece Corpus Footplates. User Weight Limit = 265 lbs.

I101988-99-0 Corpus Seat with 45° CG Pwr Tilt & Manual Recline 6,195.00 E1002Includes 45° Center of Gravity Tilt and Manual Adjustable Backrest Angle.



Required Items

I10509 Single Seat Function Ctrl Kit - C300 Tilt Only 1,478.00 E2310This item must be selected. For operation of a single seat function through the wheelchairelectronics via the VR2 Advanced Joystick Module.


Select Options:


Backrest Options


Required Items


I101853-99-0 Ergo Back Fixed 14" W x 21" H - Leatherette 837.00 E2620I101863-99-0 Ergo Back Fixed 14"W x 26.5" High - Leatherette 837.00 E2620I101854-99-0 Ergo Back Sliding 16"W x 21"H - Leatherette 837.00 E2620I101861-99-0 Ergo Back Sliding 16"W x 26.5" H - Leatherette 837.00 E2620I101855-99-0 Ergo Back Sliding 18"W x 21"H - Leatherette 837.00 E2620I101862-99-0 Ergo Back Sliding 18"W x 26.5"H - Leatherette 837.00 E2620I10472 Solid Back 16"W x 26.5"H - C300 Corpus Tilt Only No Charge

Includes Fixed Mounting Hdw, Lateral Wedges, Leatherette Cushion, and Lumbar Pads.I10473 Solid Back 18"W x 26.5"H - C300 Corpus Tilt Only No Charge

Includes Fixed Mounting Hdw, Lateral Wedges, Leatherette Cushion, and Lumbar Pads.

Seat Sizing


Required Items

I103479-99-0 Corpus Seat 17"W x 18"D No Charge

Page 3 of 6Rev 2009-4 8/24/2009 3:00:49PM



Required Items

I103480-99-0 Corpus Seat 17"W x 20"D No ChargeI103482-99-0 Corpus Seat 19"W x 18"D No ChargeI103483-99-0 Corpus Seat 19"W x 20"D No Charge


Select Options:


Armrest Options


Required Items

I10016 Height Adjustable Armrest Assembly - No Charge No Charge No charge with power tilt and/or recline.


Select Options:

I103342-99-0 4"x14" Corpus Arm Left - Dual Taper, Leatherette No Charge I103343-99-0 4"x14" Corpus Arm Right - Dual Taper, Leatherette No Charge I101003-99-0 Armrest Mount High No Charge


I304968-99-0 Corpus Armbar for 18" Btw the Arms - Installed 265.00I10001 Corpus Armbar for 20" Btw the Arms - Installed 295.00I100523-99-0 Armrest Height Ext (+2") 125.00I100671-99-0 Armrest Pouch-Right 190.00I100672-99-0 Armrest Pouch-Left 190.00

Legrest Options


Required Items

I101276-99-0 Legrest Assm. 2pc Footplates (Complete) No Charge


Required Items

I102206-99-0 Manual Adjustment Legrest Elevation No Charge


Select Options:

I10474 UT Calf Support Kit (J) w Mesh Cover & Adj Hardware 292.00 E10285"W x 6.5"T Pad.


Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium 113.00 K0108I10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108

Page 4 of 6Rev 2009-4 8/24/2009 3:00:49PM



Select Options:

I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108I100600-99-0 Positioning Belt Retractable Long 255.00 K0108I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955














Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I100975-99-0 Push Handles for Ergo Backrest 339.00







Must also select PN I10556.I100571-99-0 Upper Extremity Support Joystick Cutout 16" W 322.00 E0950



Page 5 of 6Rev 2009-4 8/24/2009 3:00:49PM



Select Options:










Signed:

Printed Name:

Title:

Date:


Page 6 of 6Rev 2009-4 8/24/2009 3:00:49PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC300 Corpus Junior



Select Options:

I10592 C300 Base Corpus R-net - C300 PS0 6,595.00 K0848Price Includes: FWD C300 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Controller, Tie-Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I10593 C300 Corpus R-net - C300 PS1 6,595.00 K0856Price Includes: FWD C300 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I103260-99-0 C300 Base Corpus R-net - C300 PS2 6,595.00 K0861Price Includes: FWD C300 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Anti-Tippers, Charger, FlatFree Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items



Required Items



Base Options


Required Items




Select Options:



Page 2 of 11Rev 2009-4 8/24/2009 3:01:13PM



Select Options:

I102769-99-0 Articulating Vent Tray for C300 1,295.00 E1030If selecting this part, you MUST also pick: PN I0036-7002A - ESP Unit. Fits an LP10 Sized Ventand a Group 34 Battery. Cannot be ordered with any backrest height less than 26.5", a tubularback, or a 13" seat depth. Customization may be required if ordered with any of the following itemsCo-Pilot, any standard attendant control, push handles, or an oxygen holder. Only available withexpandable controllers (R-net Electronics.)




Joystick Options


Required Items



Select Options:

I10412 Joystick Mount Right - Fixed, R-net Only No ChargeI10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028

Please indicate which armrest to mount midline below.I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No ChargeI10410 R-net Remote Joystick - No Charge No Charge

Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.I103814-99-0 Compact Advanced Joystick for R-net 605.00 E2373

Compact sized joystick that does not contain an LCD Display. This is an expandable/remotejoystick used with multiple power option bases or as an upgrade for no power option or singlepower option bases. Must order expandable controller (PN: I10411) with this part. Contains twomono jacks for mode & on/off. When ordering the Compact Advanced Joystick, the ICS Switchboxmust be mounted to the opposite armrests or off the backrest in order to fully access themonojacks.

I103544-99-0 R-net Remote Joystick 530.00Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.

Page 3 of 11Rev 2009-4 8/24/2009 3:01:14PM



Select Options:












Seating System


Required Items

The Seating Systems Listed Below Include:Corpus Seat Frame with 1" Depth Adjustments from 13" - 18" ( & up to 22" Deep with StandardCorpus Seat Frame) Back Frame with Adjustable Recline Angle, Reclining Armrest Assembly,Solid Seat Pan, Legrest Assembly with Adjustable Legrest Elevation, Weight Limit 165 lbs for SeatDepths Less Than 16". Weight Limit of 250 lbs for Seat Depths of 16" or Greater.

I10256 Corpus Junior Seat w/o Pwr Tilt or Pwr Recline 5,689.00 K0108I10257 Corpus Jr Seat w/ 45° CG Pwr Tilt & Manual Recline 6,830.00 E1002

Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" IncrementsI10258 Corpus Junior Seat w/ 150° Power Recline 7,356.00 E1004

Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" IncrementsI10259 Corpus Jr Seat w 45° Pwr Tilt and 150° Pwr Recline 10,695.00 E1007

Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" Increments


Page 4 of 11Rev 2009-4 8/24/2009 3:01:14PM



Select Options:











Backrest Options


Required Items


I101853-99-0 Ergo Back Fixed 14" W x 21" H - Leatherette 837.00 E2620I101863-99-0 Ergo Back Fixed 14"W x 26.5" High - Leatherette 837.00 E2620I101854-99-0 Ergo Back Sliding 16"W x 21"H - Leatherette 837.00 E2620I101861-99-0 Ergo Back Sliding 16"W x 26.5" H - Leatherette 837.00 E2620I10455 Ergo Back Fixed 14" W x 21" H - Black Mesh 859.00 E2620I10456 Ergo Back Fixed 14"W x 26.5" High - Black Mesh 859.00 E2620I10457 Ergo Back Sliding 16"W x 21"H - Black Mesh 859.00 E2620I10458 Ergo Back Sliding 16"W x 26.5" H - Black Mesh 859.00 E2620I10004 Rectangular Backrest 16"W - Plastic, Fixed 1,119.00



Standard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.

Page 5 of 11Rev 2009-4 8/24/2009 3:01:14PM



Select Options:







I10320 Omit Ergonomic Backrest Cushion No ChargeI10278 Notch Backrest Cushion for Lateral Supports 185.00

Backrest Cushion will be notched 2" in on either side to allow for closer adjustment of trunksupports.

Seat Sizing


Required Items

I10264 Corpus Junior Seat Width - Standard No ChargeCorpus seat frame is 17" wide at the outside and 15" wide between the seat rails. Actual hip widthcan be accommodated with size appropriate cushion and/or hip guides.


Required Items

I10265 Corpus Junior Seat 13" Deep No ChargeI10266 Corpus Junior Seat 14" Deep No ChargeI10267 Corpus Junior Seat 15" Deep No ChargeI10268 Corpus Junior Seat 16" Deep No ChargeI10269 Corpus Junior Seat 17" Deep No ChargeI10270 Corpus Junior Seat 18" Deep No Charge


Select Options:



I10276 Miniflex Seat Cushion Leatherette 475.00Approximately 2" thick. Not available with seat widths or depths greater than 14".

Armrest Options


Required Items

Page 6 of 11Rev 2009-4 8/24/2009 3:01:14PM



Required Items

I103339-99-0 4"x10" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103341-99-0 4"x12" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103343-99-0 4"x14" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103331-99-0 4"x10" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103333-99-0 4"x12" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103335-99-0 4"x14" Corpus Arm Right - Dual Taper, Black Fabric No Charge


Required Items

I103338-99-0 4"x10" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103340-99-0 4"x12" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103342-99-0 4"x14" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103330-99-0 4"x10" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103332-99-0 4"x12" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103334-99-0 4"x14" Corpus Arm Left - Dual Taper, Black Fabric No Charge


Select Options:





IARMADAP1" Arm Trough Adaptor 1" Pair 274.00For aftermarket arm troughs. Please indicate below if they should be installed or on chair sent asparts.







Recommend 2" wider width between the armrest to ensure armrests will flip-up.I10285 Mount Corpus Armrest Pads On Inside of Bracket No Charge


Legrest Options


Required Items


Page 7 of 11Rev 2009-4 8/24/2009 3:01:14PM



Select Options:




I100561-99-0 Legrest Assm. 1pc Footplate (Complete) 395.00I102051-99-0 Legrest Assm. 2pc Narrow Footplates (Complete) No ChargeI10271 Corpus Junior Lower Leg Length No Charge

Modification to allow for lower leg lengths of 8" - 10". Standard length is 11"-15". Measurement istaken from seat pan to the top of the footplates. Please specify lower leg length measurement ininches: ____________

IFT202SR BP Ankle Huggers, Med Side Release, Adj (Pair) 225.00 K0108This item will be sent as a part with the wheelchair. It will not be installed.

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium 113.00 K0108I10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108I100749-99-0 Miniflex Headrest Removable - Leatherette 263.00 E0955

Must also select PN I10552.I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955













Page 8 of 11Rev 2009-4 8/24/2009 3:01:14PM



Select Options:


I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I10272 Fixed Trunk Supports Jr Corpus - Leatherette 246.00 E0956

Must also select PN I10551.I10274 Swing Away Trunk Supports Jr Corpus - Leatherette 265.00 E0956






Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00ISH212 BP Shoulder Harness Medium, Front Pull 196.00 E0960

This item will be sent as a part with the wheelchair. It will not be installed.I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950




Must also select PN I10556.I100573-99-0 Upper Extremity Support Mid Joystick Cutout 16"W 395.00 E0950

Must also select PN I10556.I103426-99-0 Upper Extremity Support Angle Adjust - UniTrack 296.00 E0950

Side mounted tray that attaches to the UniTrack Accessory Rail. Dimensions are: 19.5"W x 13"D.Can only be ordered with chairs that offer the UniTrack System. Must also select PN I10556.






Required Items

Page 9 of 11Rev 2009-4 8/24/2009 3:01:14PM



Required Items

















Select Options:



Page 10 of 11Rev 2009-4 8/24/2009 3:01:14PM



Required Items



Required Items



Required Items






Select Options:







Signed:

Printed Name:

Title:

Date:


Page 11 of 11Rev 2009-4 8/24/2009 3:01:14PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListK300 PS Jr



Select Options:

I103573-99-0 K300 Base PS - C300 PS0 6,795.00 K0848Price Includes: FWD C300 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Controller, Tie-Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I10431 K300 Base PS - C300 PS1 6,795.00 K0856Price Includes: FWD C300 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I10520 K300 Base PS - C300 PS2 6,795.00 K0861Price Includes: FWD C300 Power Base Set Up For Two Power Seat Functions, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Anti-Tippers,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.


Required Items



Required Items

I103576-99-0 C300/K300 Shroud - Onyx Black No ChargeI101383-99-0 C300/K300 Shroud - Crystal Blue No ChargeI103577-99-0 C300/K300 Shroud - Platinum Silver No ChargeI101385-99-0 C300/K300 Shroud - Green Metallic No ChargeI103575-99-0 C300/K300 Shroud - Titan Blue No ChargeI103578-99-0 C300/K300 Shroud - Pop Star Pink No ChargeI103574-99-0 C300/K300 Shroud - Chili Pepper Red No Charge


Required Items



Base Options


Required Items

I101995-99-0 Fixed Seat Tube for Tilt No ChargeI103779-99-0 Power Adjustable Seat Height - 8" Travel 2,395.00 E2300

To assist in transfers and improve access for function.


Select Options:



Page 2 of 9Rev 2009-4 8/24/2009 3:05:56PM



Select Options:




Permolock


Select Options:



Joystick Options


Required Items



Select Options:

I10412 Joystick Mount Right - Fixed, R-net Only No ChargeI10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028ID51108 R-net LED Remote Joystick Module No Charge

Standard Joystick Module. This Joystick does NOT have an LCD Display and does NOT containmono jacks. Limited to five profiles with this Joystick Module. Must order expandable controller(PN I10411) with this part if ordering two or more seat functions. Please note if ordering this item,the ICS Switchbox must be mounted onto either the armrest pad or the backrest. Cannot order PN:I1822845 or I103469-99-0 with this style of joystick.

Page 3 of 9Rev 2009-4 8/24/2009 3:05:56PM



Select Options:

I103814-99-0 Compact Advanced Joystick for R-net 605.00 E2373Compact sized joystick that does not contain an LCD Display. This is an expandable/remotejoystick used with multiple power option bases or as an upgrade for no power option or singlepower option bases. Must order expandable controller (PN: I10411) with this part. Contains twomono jacks for mode & on/off. When ordering the Compact Advanced Joystick, the ICS Switchboxmust be mounted to the opposite armrests or off the backrest in order to fully access themonojacks.












Seating System


Required Items

I103712-99-0 PS Junior Seat Frame - Only No ChargeWeight limit 165lbs.

I103715-99-0 PS Jr Seat w/ 45° Manual Tilt 425.00 K0108Must be ordered with Stroller Handles (I103811-99-0). Weight limit 165lbs.

I103716-99-0 PS Junior Seat Frame with 45° Power Tilt 5,250.00 E1002Weight limit 165lbs.


Page 4 of 9Rev 2009-4 8/24/2009 3:05:56PM



Select Options:









Backrest Options


Required Items

I103717-99-0 PS Jr Back Canes, Height & Angle Adjustable No ChargeMust also select PS Jr Style Armrests if ordering this backrest. Choose PS Jr Style Backrest Type(Solid Back, Sling Back, or Omit Back) below. Backrest width should match seat width. Back heightis adjustable from 16.5"T - 22.5"T, measured from the seat pan to the top of the back.


Required Items

I10448 PS Jr Curved Metal Backrest No ChargeBackrest width will match seat width. Back height is adjustable from 16.5"T - 22.5"T, measuredfrom the seat pan to the top of the backrest.

I10449 PS Jr - Omit Backrest No Charge

Seat Sizing


Required Items

I10432 PS Jr Seat Width 11" No ChargeI10433 PS Jr Seat Width 12" No ChargeI10434 PS Jr Seat Width 13" No ChargeI10435 PS Jr Seat Width 14" No ChargeI10436 PS Jr Seat Width 15" No ChargeI10437 PS Jr Seat Width 16" No Charge

Page 5 of 9Rev 2009-4 8/24/2009 3:05:56PM



Required Items

I10438 PS Jr Seat Depth 10" No ChargeI10439 PS Jr Seat Depth 11" No ChargeI10440 PS Jr Seat Depth 12" No ChargeI10441 PS Jr Seat Depth 13" No ChargeI10442 PS Jr Seat Depth 14" No ChargeI10443 PS Jr Seat Depth 15" No ChargeI10444 PS Jr Seat Depth 16" No ChargeI10445 PS Jr Seat Depth 17" No ChargeI10446 PS Jr Seat Depth 18" No Charge


Select Options:



Armrest Options


Required Items

I104648-99-0 Height Adj Arm Assembly - PS Jr w/ UT Arm Pads 284.00 E0973Newly Redesigned! Includes: 40° of angle adjustability, unlimited rotational adjustment, and 2" ofoffset adjustment medially and laterally. Height adjustment in 1" increments from 7" - 11" from theseat pan. Includes "C" Sized UT Armrest Pad (8"L x 3.5"W). Height Adjustable Armest Assembly isno charge if ordering Power Tilt. Other sized armpads are be available upon request.

I10519 Height Adj Arm Assembly - PS Jr w/ UT Arm Pads - NC No ChargeNo Charge when ordering Powered Tilt.

Legrest Options


Required Items

I10586 70 Degree Swing Away Legrests - PS Jr No ChargeI10587 90 Degree Swing Away Legrests - PS Jr No Charge


Required Items

I10590 Multi-Axis Angle Adjust Footplates - 5"W x 8"D No Charge


Select Options:


Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium 113.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108

Page 6 of 9Rev 2009-4 8/24/2009 3:05:56PM



Select Options:

I100749-99-0 Miniflex Headrest Removable - Leatherette 263.00 E0955Must also select PN I10552.


I10552 Adj Removable - Headrest Hardware (1 Each) 212.00 E1028I103077-99-0 UT Hip Suppt (B) w/ Mesh Cover - Low (Pair) 225.00 E0956

4.5"W x 3.5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) 225.00 E0956

6.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I103811-99-0 Stroller Handle for PS Jr Seating System 182.00

Angle adjustable. This item Must be selected when ordering manual tilt (I103715-99-0).I101473-99-0 Back Pack Clips Carabiner Style 75.00I102059-99-0 Medical Necessities Bag 265.00

Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00ISH212 BP Shoulder Harness Medium, Front Pull 196.00 E0960

This item will be sent as a part with the wheelchair. It will not be installed.I103426-99-0 Upper Extremity Support Angle Adjust - UniTrack 296.00 E0950


I10556 Adj Removable - Tray Hardware (1 Each) 212.00 E1028I103798-99-0 After Market Seating System Adapter 75.00 K0108

Used to connect after market seating systems to the UniTrack Accessory Rail on the PS Jr SeatFrame. Includes Mounting Hardware.

Custom Swing Awy Laterals Available Upon Request



Required Items





For neck width up to 7".I10564 Mini Joystick set up for Armrest Mount 2,035.00 E2312I10565 Mini Joystick set up for Midline Mount 2,035.00 E2312I10567 Mini Joystick w/ Haims Harness - Small 2,135.00 E2312




Page 7 of 9Rev 2009-4 8/24/2009 3:05:56PM



Required Items







Select Options:




Required Items



Required Items



Required Items






Select Options:


Page 8 of 9Rev 2009-4 8/24/2009 3:05:56PM



Select Options:







Signed:

Printed Name:

Title:

Date:


Page 9 of 9Rev 2009-4 8/24/2009 3:05:56PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListK450 MX



Select Options:

I104524-99-0 K450 Base w/ R-net 5.2mph - K450 PS2 11,845.00 K0891Price Includes: K450 Power Base Set Up For Multiple Power Seat Functions, Tie-Down Hardwarefor Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Freeor Pneumatic Tires Below.


Required Items

I104525-99-0 Flat Free Drive Tires - K450 No ChargeI10607 Pneumatic Drive Tires & Flat Free Casters - K450 No Charge


Required Items

I104534-99-0 Shroud for K450 - Chili Pepper Red No ChargeI104535-99-0 Shroud for K450 - Onyx Black No ChargeI104536-99-0 Shroud for K450 - Platinum Silver No ChargeI104537-99-0 Shroud for K450 - Pop Star Pink No ChargeI104538-99-0 Shroud for K450 - Titan Blue No ChargeI104539-99-0 Shroud for K450 - Extreme Yellow No Charge

Base Options


Required Items

I10510 Power Adjustable Seat Height - 8" Travel 2,495.00 E2300This item must be selected.


Select Options:

IM34 SLDG Batteries - Group 34, 12V 60 Amp Hours, Installed 762.00 K0108I104550-99-0 Anti-Tippers for K450 395.00I104540-99-0 Light Kit - K450 R-net 985.00

Not compatible with the Compact Advanced Joystick.I104553-99-0 WC 19 Transit Kit - K450 1,585.00

This kit includes additional anchor points for tie down straps, seat stabilizing bars and hardware,and a WC-19 Approved integrated lap and shoulder belt. This kit has been approved according toANSI/RESNA WC19. Cannot be ordered with a 10"W Seat Size (I104317-99-0). An ICS Switchboxmust be installed on the chair in order to access WC19 mode.

I104554-99-0 Fixed Ventilator Tray - K450 525.00 E1029Tray is 9 .75"D x 13"W, and increases the overall length of a K450 by approximately 11". Theventilator tray is designed to accommodate an LP10 style ventilator and one U1 Battery. A customcharge will need to be applied if ordering vent tray with any of the following items: WC-19 TransitKit (I104553-99-0), Attendant Control (ID50882), Push Handles (I104576-99-0), or Back PackClips (I10598).


Permolock


Select Options:

Page 2 of 10Rev 2009-4 8/24/2009 3:14:21PM



Select Options:


I104652-99-0 Permolock C3 Dual Locking Pin Kit - K450 595.00This kit includes two pins that are mounted underneath the base of the wheelchair. The pins arefixed and do not push into the wheelchair base.

Joystick Options


Required Items



Select Options:

I10412 Joystick Mount Right - Fixed, R-net Only No ChargeI10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028ID51108 R-net LED Remote Joystick Module No Charge

Standard Joystick Module. This Joystick does NOT have an LCD Display and does NOT containmono jacks. Limited to five profiles with this Joystick Module. Must order expandable controller(PN I10411) with this part if ordering two or more seat functions. Please note if ordering this item,the ICS Switchbox must be mounted onto either the armrest pad or the backrest. Cannot order PN:I1822845 or I103469-99-0 with this style of joystick.

I103814-99-0 Compact Advanced Joystick for R-net 605.00 E2373Compact sized joystick that does not contain an LCD Display. This is an expandable/remotejoystick used with multiple power option bases or as an upgrade for no power option or singlepower option bases. Must order expandable controller (PN: I10411) with this part. Contains twomono jacks for mode & on/off. When ordering the Compact Advanced Joystick, the ICS Switchboxmust be mounted to the opposite armrests or off the backrest in order to fully access themonojacks.

ID51036 R-net Remote Joystick w/ Mono Jacks 530.00Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. Must order expandable controller (PN: I10411) with this part.Comes standard w/ mono jacks.



Page 3 of 10Rev 2009-4 8/24/2009 3:14:21PM



Select Options:






ID50882-A Attendant Control for R-net Control System Only 1,084.00 E2331On the K450, the mounting location for the Attendant Control is off of the Push Handle Bracket. Ifordering an attendant control, you must also order I104576-99-0 (Push Handles - MX Seat).


Seating System


Required Items

I104324-99-0 MX Power Seating System 6,455.00 K0108Price Includes: MX Seating System, Adjustable Seat Frame, Power Seat to Floor System,Adjustable Backrest Angle, and One Piece Footplate. Weight Limit 125lbs.


Required Items

I104529-99-0 No Tilt No ChargeWeight Limit 125lbs.

I104551-99-0 45° Power Tilt 5,309.00 E1002Weight Limit 125lbs.



Required Items



Required Items

I104136-99-0 Toggles on Seat Function Control Kit 225.00I104135-99-0 Push Buttons on Seat Function Control Kit No Charge


Select Options:

I1822845 Mount ICS Switchbox onto R-net Joystick Bracket No ChargeICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item isselected, the ICS Switchbox will swing away with the Joystick Module.

Page 4 of 10Rev 2009-4 8/24/2009 3:14:21PM



Select Options:

I1822846 Mount ICS Switchbox onto End of Armrest Pad No ChargeICS Switchbox will be mounted to the end of the armrest pad. If this item is selected, the ICSSwitchbox will NOT swing away with the Joystick Module. Please indicate below if you would like itmounted onto the left or right arm pad.





I10515 Memory Seat Program for K450 MX No ChargeIf this is selected, the chair will be programmed to allow the user to store and save up to 3 differentmemory seat positions through the ICS Switchbox. On the K450 MX, ALL seat functions arecapable of recalling a saved seat position. Please refer to the K450 Owner's Manual for moreinformation on saving and recalling a memory seat position.

Backrest Options


Required Items

MX STYLE BACKRESTS:Use this section to select MX Style Backrests. Back heights measured from the seat pan to the topof the backrest shell with the backrest set at 90°. Please be sure to pick both a backrest shell sizeand a backrest cushion style (Leatherette or Black Mesh Fabric). Note: A 16"W MX Backrest isNOT available.

I104321-99-0 MX Backrest - 10"W x 14"H No ChargeBackrest can be adjusted to either 14" or 16" high. Backrest will be mounted in the 16" high positionif ordering a headrest.

I104322-99-0 MX Backrest - 12"W x 16"H No ChargeBackrest can be adjusted to either 16" or 18" high.

I104323-99-0 MX Backrest - 14"W x 20"H No ChargeBackrest can be adjusted to either 20" or 22" high.


Required Items

Please Select Cushion Style Below:I104309-99-0 MX Back Cushion 270x325, 10"W x 14"T - Leatherette No ChargeI104311-99-0 MX Back Cushion 320x375, 12"W x 16"T - Leatherette No ChargeI104313-99-0 MX Back Cushion 370x475, 14"W x 20"T - Leatherette No ChargeI104308-99-0 MX Back Cushion 270x325, 10"W x 14"T - Black Mesh No ChargeI104310-99-0 MX Back Cushion 320x375, 12"W x 16"T - Black Mesh No ChargeI104312-99-0 MX Back Cushion 370x475, 14"W x 20"T - Black Mesh No Charge


Required Items

PS JR TUBULAR STYLE BACKRESTSUse this section to select PS Jr Tubular Style Backrest Canes. Note: A 10"W Tubular Backrest isNOT available.

Page 5 of 10Rev 2009-4 8/24/2009 3:14:21PM



Required Items

I103717-99-0 PS Jr Back Canes, Height & Angle Adjustable No ChargeMust also select PS Jr Style Armrests if ordering this backrest. Choose PS Jr Style Backrest Type(Solid Back, Sling Back, or Omit Back) below. Backrest width should match seat width. Back heightis adjustable from 16.5"T - 22.5"T, measured from the seat pan to the top of the back.


Required Items

I103719-99-0 PS Jr Solid Backrest - 12"W No ChargeI103721-99-0 PS Jr Solid Backrest - 14"W No ChargeI103723-99-0 PS Jr Solid Backrest - 16"W No Charge

Standard headrests will not mount to sling backs.I103725-99-0 PS Jr Sling Backrest - 12"W No ChargeI103727-99-0 PS Jr Sling Backrest - 14"W No ChargeI103729-99-0 PS Jr Sling Backrest - 16"W No ChargeI10449 PS Jr - Omit Backrest No Charge


Select Options:

Seat Sizing


Required Items

I104317-99-0 MX Seat Size 10"W x 10"D No ChargeSeat depth can be adjusted to 10", 11", or 12". If ordering this seat size, the lowest allowed seatposition when using the seat to floor function will be approximately 3.5" from the floor to the top ofthe seat pan. This seat size is not compatible with the WC 19 Kit (I104553-99-0).

I104318-99-0 MX Seat Size 12"W x 12"D No ChargeSeat depth can be adjusted to 12", 13", or 14". If ordering this seat size, the lowest allowed seatposition when using the seat to floor function will be approximately 3.5" from the floor to the top ofthe seat pan.

I104319-99-0 MX Seat Size 14"W x 14"D No ChargeSeat depth can be adjusted to 14", 15", or 16". If ordering this seat size, with MX Arms, the lowestallowed seat position when using the seat to floor function will be approximately 3.5" from the floorto the top of the seat pan. If ordering PS Jr Arms, the lowest allowed seat position will be 10".

I104320-99-0 MX Seat Size 16"W x 16"D No ChargeSeat depth can be adjusted to 16", 17", or 18". If ordering this seat size with MX Arms, the lowestallowed seat position when using the seat to floor function will be approximately 10" from the floorto the top of the seat pan. If ordering PS Jr Arms, the lowest allowed seat position will be 16".


Select Options:

Seat Cushions Below Are Approximately 2" Thick:I306384-99-90-0 Leatherette Seat Cush MX - 10"W x 10"D (250x250) 475.00I306385-99-90-0 Leatherette Seat Cush MX - 12"W x 12"D (300x300) 475.00I306386-99-90-0 Leatherette Seat Cush MX - 14"W x 14"D (350x350) 475.00I101818-99-0 Leatherette Seat Cush MX - 16"W x 16"D (400x400) 475.00I104305-99-0 Black Mesh Seat Cush MX - 10"W x 10"D (250x250) 485.00I104306-99-0 Black Mesh Seat Cush MX - 12"W x 12"D (300x300) 485.00I104307-99-0 Black Mesh Seat Cush MX - 14"W x 14"D (350x350) 485.00I104702-99-0 Black Mesh Seat Cush MX - 16"W x 16"D (400x400) 485.00

Armrest Options

Page 6 of 10Rev 2009-4 8/24/2009 3:14:21PM



Required Items

I10512 Height Adjustable Armrest Assembly MX Seat 284.00 E0973If you are not selecting Tilt, you MUST order this item.

I10514 Height Adjustable Armrest Assembly MX Seat - NC No ChargeNo Charge if ordering Power Tilt (I104551-99-0)


Required Items

I104303-99-0 MX Armrest Pad Short Leatherette 8"L x 4"W No ChargeI104304-99-0 MX Armrest Pad Long Leatherette 12.5"Lx3.5"W No Charge


Required Items

I104648-99-0 Height Adj Arm Assembly - PS Jr w/ UT Arm Pads 284.00 E0973Newly Redesigned! Includes: 40° of angle adjustability, unlimited rotational adjustment, and 2" ofoffset adjustment medially and laterally. Height adjustment in 1" increments from 7" - 11" from theseat pan. Includes "C" Sized UT Armrest Pad (8"L x 3.5"W). Height Adjustable Armest Assembly isno charge if ordering Power Tilt. Other sized armpads are be available upon request.

I10519 Height Adj Arm Assembly - PS Jr w/ UT Arm Pads - NC No ChargeNo Charge when ordering Powered Tilt.

Legrest Options


Required Items

I104314-99-0 MX Footplate - Small (11.5" W x 8"D) No ChargeI104315-99-0 MX Footplate - Large (14" W x 9.5"D) No Charge


Select Options:

I103427-99-0 Footstrap Kit 165.00I103104-99-0 Footstrap Kit - Padded 185.00I104338-99-0 Small Anti-Skid Overlay for Footplate - K450 125.00I104337-99-0 Large Anti-Skid Overlay for Footplate - K450 125.00IFT202SR BP Ankle Huggers, Med Side Release, Adj (Pair) 225.00 K0108

This item will be sent as a part with the wheelchair. It will not be installed.

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium 113.00 K0108I104339-99-0 MF Headrest for MX Seat - Leatherette 263.00 E0955

Must also select PN I10552. Also includes a UT Bracket for lateral adjustment of the headrest.Please indicate below which size you need.

I104344-99-0 UT Bracket for Lateral Head Adj (10"W MX Back) No ChargeAllows for Lateral Adjustment of the headrest.

I104345-99-0 UT Brack for Lateral Head Adj (12-14"W MX Back) No ChargeAllows for Lateral Adjustment of the headrest.



4.5"W x 3.5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.

Page 7 of 10Rev 2009-4 8/24/2009 3:14:21PM



Select Options:


I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I104575-99-0 UT Lateral Suppt (B) for MX Seat - 3.5"T x 4.5"D 285.00 E0956

Must also select PN I10551.I104574-99-0 UT Lateral Suppt (F) for MX Seat - 3.5"T x 8.5"D 285.00 E0956

Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I104576-99-0 Push Handles - K450 345.00

Mounted off the chassis. Height and angle adjustable. Must be selected if ordering backpack clipsor an attendant control.

I10598 Back Pack Clips Carabiner Style 75.00Push Handles (I104576-99-0) must also be selected in order to mount backpack clips.

I100598-99-0 Chest Harness 371.00 E0960Chest harness kit includes a standard positioning belt.

ISH212 BP Shoulder Harness Medium, Front Pull 196.00 E0960This item will be sent as a part with the wheelchair. It will not be installed.

I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950Must also select PN I10556.


I10556 Adj Removable - Tray Hardware (1 Each) 212.00 E1028



Required Items





For neck width up to 7".I10564 Mini Joystick set up for Armrest Mount 2,035.00 E2312I10565 Mini Joystick set up for Midline Mount 2,035.00 E2312I10567 Mini Joystick w/ Haims Harness - Small 2,135.00 E2312





Page 8 of 10Rev 2009-4 8/24/2009 3:14:21PM



Required Items






Select Options:




Required Items



Required Items



Required Items





Select Options:


Page 9 of 10Rev 2009-4 8/24/2009 3:14:21PM






Signed:

Printed Name:

Title:

Date:


Page 10 of 10Rev 2009-4 8/24/2009 3:14:21PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListChairman Koala Mini-Flex



Select Options:

I100855-99-0 Koala Miniflex w/Pilot+ 7,995.00 K0890Price Includes: FWD Koala Power Base Set Up For One Power Seat Function, Tie-DownHardware for Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must ChooseFlat Free or Pneumatic Tires Below.


Required Items

I103889-99-0 Tri Spoke Split Rim w/ FF Drive Tires - 2.5 x 8" No ChargeI103890-99-0 Tri Spoke Split Rim w/ Pneumatic Tire - 2.5 x 8" No Charge


Required Items

I100859-99-0 Shroud for Koala - Yellow No ChargeI100858-99-0 Shroud for Koala - Red No ChargeI101317-99-0 Shroud for Koala - Purple Ice No Charge


Required Items


Base Options


Select Options:

IM40-12 SLD G Batteries, Koala Sealed LA/Gel, Installed 692.00I100864-99-0 Light Kit - Koala 800.00I602307-99-0 P+ PP1A Programmer - VSI, VR2 or Pilot+ Controllers 595.00I100865-99-0 Front Bumper Koala 495.00

Joystick Options


Required Items



Select Options:

I10127 Fixed Joystick Mount - Right No ChargeI10136 Fixed Joystick Mount - Left No ChargeI100849-99-0 Joystick Mount-Right Swing Away 292.00 E1028I100848-99-0 Joystick Mount-Left Swing Away 292.00 E1028

Page 2 of 8Rev 2009-4 8/24/2009 3:13:20PM



Select Options:

I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028Please indicate which armrest to mount midline below.

I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No ChargeID49670/3 Pilot+ series Joystick w/ 7 Buttons - No Charge No Charge

Comes standard when ordering zero or one power option.I10207 Pilot+ Series Joystick w/ 7 Buttons 530.00

Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. MUST order expandable controller (PN: I10450) with this part.

ID49880 Pilot+ Joystick M/J 530.00Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. MUST order expandable controller (PN: I10450) with this part.1/8" mini-mono jacks for power and mode.

ID50002 Pilot+Series Joystick T/S 530.00Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. MUST order expandable controller (PN: I10450) with this part.Toggle switches for power and mode.

I10450 Expandable Controller - Pilot Plus 525.00 E2377MUST be ordered with the expandable/remote joysticks (PN: I10207, ID49880, or ID50002).


ID49682 P+DAC Attendant Control - Pilot+ Controller Only 1,136.00 E2331Not available with VR2 controllers. Will be sent as part if ordering sling back upholstery.

I103182-99-0 Co-Pilot Attendant Control - MiniFlex 2,626.00 E2331Custom charge will be applied if ordering with a tubular backrest. (PN: I10113, I10114).

Seating System


Required Items

IKOALA-MFII Mini Flex Seating System 6,497.00 K0108Price Includes: Mini Flex Seating System, Power Tilt System, Adjustable Seat Frame, AdjustableBackrest and Legrest Angle, Positioning Belt and One Piece Footrest. Weight Limit 110 lbs.



Select Options:

I10128 Single Seat Function Control Switch No ChargeI10129 Single Seat Function Control Kit 1,478.00 E2310

For operation of a single seat function through the wheelchair electronics via the drive controlsand/or membrane switch box. Order with Pilot+ or remote joystick options. Not available with VSIControllers.

I100579-99-0 Multiple Seat Function Control Kit 2,875.00 E2311MUST be selected if ordering two or more seat functions. This device is used to operate two ormore seat functions through the wheelchair electronics via the drive controls and/or membraneswitch box. Order with Pilot+ or remote joystick options. Not available with VSI Controllers.

I100524-99-0 Toggle Switch Kit For Seat Function Control Kit 128.00 K0108Add on part for either the multiple seat function control kit or single seat function control kit in order.

ISW-JOY Seat Control Joyswitch 1,451.00 K0108Multi directional toggle to operate up to 4 power seat functions. Provides an additional method toaccessing the seat functions. You must still order the Multiple Seat Function Control Kit if selectingthis part. Please specify where to mount membrane switchbox: Right Arm Pad: _____ LeftArmrest Pad:_____

Page 3 of 8Rev 2009-4 8/24/2009 3:13:20PM



Select Options:

I10253 Mount Joyswitch on Left No ChargeI10254 Mount Joyswitch on Right No ChargeISW-ALT Altswitch Alternating Seat Control 985.00 K0108

Seat function interface box which accommodates 4 single momentary switches. 1/8" mini-monoswitches not included. Provides an additional method to accessing the seat functions. You muststill order the Multiple Seat Function Control Kit if selecting this part.


Backrest Options


Required Items


I100764-99-0 Backrest Kit 10"W x 14"H Leatherette No ChargeI100765-99-0 Backrest Kit 12"W x 16"H Leatherette No ChargeI100766-99-0 Backrest Kit 14"W x 20"H Leatherette No ChargeI100761-99-0 Backrest Kit 10"W x 14"H Fabric No ChargeI100762-99-0 Backrest Kit 12"W x 16"H Fabric No ChargeI100763-99-0 Backrest Kit 14"W x 20"H Fabric No ChargeI10113 Tubular Backrest Frame Mini-Flex, 12" Wide No Charge

Backrest canes to mount aftermarket backrest systems.I10114 Tubular Backrest Frame Mini-Flex, 14" Wide No Charge

Backrest canes to mount aftermarket backrest systems.

Seat Sizing


Required Items

I100757-99-0 Seat Sizing 10"W x 10"D Leatherette No ChargeI100758-99-0 Seat Sizing 12"W x 12"D Leatherette No ChargeI100759-99-0 Seat Sizing 14"W x 14"D Leatherette No ChargeI100754-99-0 Seat Sizing 10"W x 10"D Fabric No ChargeI100755-99-0 Seat Sizing 12"W x 12"D Fabric No ChargeI100756-99-0 Seat Sizing 14"W x 14"D Fabric No ChargeI10115 Tubular Seat Frame Mini-Flex, 12" Wide No Charge

Seat frame tubes to mount aftermarket seating systems.I10116 Tubular Seat Frame Mini-Flex, 14" Wide No Charge

Seat frame tubes to mount aftermarket seating systems.

Armrest Options


Required Items

I100770-99-0 Armrest Left, 8" Leatherette No ChargeI100768-99-0 Armrest Left, 8" Fabric No ChargeI100774-99-0 Armrest Left, 10" Leatherette No Charge

Page 4 of 8Rev 2009-4 8/24/2009 3:13:20PM



Required Items

I100772-99-0 Armrest Left, 10" Fabric No Charge


Required Items

I100769-99-0 Armrest Right, 8" Leatherette No ChargeI100767-99-0 Armrest Right, 8" Fabric No ChargeI100773-99-0 Armrest Right, 10" Leatherette No ChargeI100771-99-0 Armrest Right, 10" Fabric No Charge


Select Options:


No charge with power tilt and/or recline.

Legrest Options


Select Options:

I101088-99-0 Footplate, Small w/ 5-12" Pan to Ftplate Adj. No ChargeI101089-99-0 Footplate, Large w/ 5-12" Pan to Ftplate Adj. No ChargeI100599-99-0 Foot Strap Kit 75.00 E0951,E0952IFT202SR BP Ankle Huggers, Med Side Release, Adj (Pair) 225.00 K0108

This item will be sent as a part with the wheelchair. It will not be installed.

Accessories


Select Options:

I100518-99-0 Positioning Belt No ChargeStandard positioning belt is included in the basic equipment package.

I100519-99-0 Positioning Belt Retractable 235.00 K0108I100748-99-0 Miniflex Headrest Removable - Fabric 292.00 E0955

Must also select PN I10552.I100749-99-0 Miniflex Headrest Removable - Leatherette 263.00 E0955

Must also select PN I10552.IHEADADAPTER Universal Headrest Adapter 197.00 K0108

For aftermarket headrests.I10552 Adj Removable - Headrest Hardware (1 Each) 212.00 E1028I100753-99-0 Thigh Support Kit Leatherette 246.00 E0956

Must also select PN I10550.I100752-99-0 Thigh Support Kit Fabric 284.00 E0956

Must also select PN I10550.I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I100751-99-0 Lateral Supports Leatherette 246.00 E0956

Must also select PN I10551.I100750-99-0 Lateral Supports Fabric 284.00 E0956

Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I100867-99-0 Knee Block Leatherette 467.00 K0108I100866-99-0 Knee Block Fabric 508.00 K0108I101473-99-0 Back Pack Clips Carabiner Style 75.00

Page 5 of 8Rev 2009-4 8/24/2009 3:13:20PM



Select Options:

I100598-99-0 Chest Harness 371.00 E0960Chest harness kit includes a standard positioning belt.

ISH212 BP Shoulder Harness Medium, Front Pull 196.00 E0960This item will be sent as a part with the wheelchair. It will not be installed.

I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950Must also select PN I10556.




Required Items

Pilot Plus Alternative Drive Input DevicesPilot + Alt Drive Input Devices take the place of, or may be used in addition to, the standard Pilot +Joystick. They are only usable on wheelchairs that have Pilot + electronics. You MUST select oneof each of the following items: (1) Input Device, (2) Expandable Controller, (3)Adjustable/Removable Alt Drive Hardware, AND (4) Omni Plus Control Module.
















Select Options:

Page 6 of 8Rev 2009-4 8/24/2009 3:13:20PM



Select Options:




Required Items



Required Items



Required Items

(4) OMNI PLUS CONTROL MODULE (REQUIRED)I10073 Omni Plus Control Module for Pilot Plus 1,470.00 E2399

Please specify input method if not ordering from Permobil. Input Device:________________________



Select Options:

IMICROSWITCH Microlite Switch 148.00IBUDDYBUTTON Buddy Button 111.00 K0108I5808 Mini Cup Switch 108.00IZTS-P Proximity Switch 515.00IMINIJOY5SW Mini Joystick 5 Switch OC 593.00I5018 Wafer Board w/5 Switches 497.00ID00005 Dual Control Switch Box 859.00ID49871 Auxiliary Control Module 877.00 E2351I10082 Chin Control Unit Stand Alone 1,215.00 E2373,E1028

Includes: P & G Chin Control Unit and swing away mount off the backrest. (Do not need Omni PlusControl Module).

Page 7 of 8Rev 2009-4 8/24/2009 3:13:20PM






Signed:

Printed Name:

Title:

Date:


Page 8 of 8Rev 2009-4 8/24/2009 3:13:20PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:




Select Options:

I10421 C350 Base 5mph - C350 PS0 6,595.00 K0848Price Includes: RWD C350 Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, VR2 Controller with 5mph Motor Programming, Tie-Down Hardware for StrapSystems, Charger, Flat Free Tires, and Bodypoint Standard Positioning Belt. Must Choose FlatFree or Pneumatic Tires Below.

I10422 C350 Base 5mph - C350 PS1 6,595.00 K0856Price Includes: RWD C350 Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, VR2 Controller with 5mph Motor Programming, Tie-Down Hardware for StrapSystems, Charger, Flat Free Tires, and Bodypoint Standard Positioning Belt. Must Choose FlatFree or Pneumatic Tires Below.

I10604 6.5mph High Speed Upgrade Package - C350 1,380.00Upgrade option for Group 3 C350 Power Base. This option is only available on C350 Power Baseswith R-net Electronics.

I10554 C350 Base 6.5mph - C350 HS PS2 7,975.00 K0884Price Includes: RWD C350 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, 6.5mph Motor Programming, Tie-Down Hardware for StrapSystems, Anti-Tippers, Flat Free Tires, and Standard Bodypoint Positioning Belt. If selecting thisBase, you MUST also select R-net Electronics. The 6.5mph Speed Package is NOT available withVR2 Electronics. Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items

I103532-99-0 C350 Shroud Vintage Wine No ChargeI103533-99-0 C350 Shroud Crystal Blue No ChargeI103529-99-0 C350 Shroud Onyx Black No ChargeI103530-99-0 C350 Shroud Platinum Silver No ChargeI103531-99-0 C350 Shroud Extreme Yellow No Charge


Required Items



Base Options


Required Items

I103524-99-0 Power Adjustable Seat Height, 8" Travel 2,395.00 E2300To assist in transfers and improve access for function.



Select Options:

IM34 SLDG Batteries - Group 34, 12V 60 Amp Hours, Installed 762.00 K0108I602307-99-0 P+ PP1A Programmer - VSI, VR2 or Pilot+ Controllers 595.00I103496-99-0 Light Kit for C350 955.00

Cannot be ordered with VR2 Electronics.

Page 2 of 10Rev 2009-4 8/24/2009 3:07:08PM



Select Options:


Permolock


Select Options:


I10609 Permolock C3 Dual Locking Pin Kit - C350 595.00This kit includes two spring loaded pins that will be mounted underneath the base of thewheelchair. These pins are spring loaded so they push into the wheelchair base when an obstacleis encountered. The kit also includes a set of reinforced braces must be installed whenever thespring loaded pins are mounted in a C350 Base.

Joystick Options


Required Items



Select Options:

I10424 Fixed Joystick Mount - Right - VR2 No ChargeI10425 Fixed Joystick Mount - Left VR2 No ChargeI10412 Joystick Mount Right - Fixed, R-net Only No ChargeI10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028

Please indicate which armrest to mount midline below.I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No ChargeI10423 VR2 Basic Joystick - Standard No ChargeI103544-99-0 R-net Remote Joystick 530.00


Page 3 of 10Rev 2009-4 8/24/2009 3:07:09PM



Select Options:











Seating System


Required Items

I10281 PS Seating System Only - C300/C350 No ChargeIncludes: Seat Frame, Fixed Back Frame, Fixed Legrests and Footplates, Fixed Arm Supports andStandard Armrest Pads. Weight Limit 300 lbs.

I10142 PS Seating System With 45 Degree CG Power Tilt 4,763.00 E1002Price Includes: Seat Frame, All Seat Sizes, Angle Adjustable Back Canes, Height AdjustableArmrests, Standard Armrest Pads, Swing Away Legrests and Footplates. Weight Limit 300lbs.



Select Options:

I10289 Single Seat Function Control Switch - LiberT No ChargeThis device is a single toggle switch used to control only one seat function. If control of the seatfunction through the drive control is needed, then the drive electronics must be upgraded to Pilot+or R-net Electronics, and a Single Seat Function Control Kit (Part Number I10129), must beselected.

Page 4 of 10Rev 2009-4 8/24/2009 3:07:09PM



Select Options:









Backrest Options


Required Items

I10144 Sling Upholstery Back Support - Standard No ChargeWidth will be the same as seat width.

I10145 Curved Metal Back Support 22" High 410.00I10146 Curved Metal Back Support 22" High - No Charge No Charge

No charge if ordering tilt.I10454 Omit Backrest No Charge


Required Items

I10148 Angle Adjustable Back Canes 127.00Angle adjustable from 85 to 115 degrees.

I10149 Angle Adjustable Back Canes - No Charge No ChargeNo charge if ordering tilt.

Seat Sizing


Required Items

I10150A Seat Width 16" No ChargeI10151A Seat Width 18" No ChargeI10219A Seat Width 20" No Charge

Page 5 of 10Rev 2009-4 8/24/2009 3:07:09PM



Required Items

I10220A Seat Width 22" No Charge


Required Items

I10156 Seat Depth 16" No ChargeI10157 Seat Depth 17" No ChargeI10158 Seat Depth 18" No ChargeI10159 Seat Depth 19" No ChargeI10221 Seat Depth 20" No ChargeI10222 Seat Depth 21" No ChargeI10223 Seat Depth 22" No Charge

Armrest Options


Required Items

I10164 Fixed Height Armrest Assembly PS No ChargeFlips back for transfers.

I10163 Height Adjustable Armrest Assembly PS 284.00 E0973Adjustable in height, with a flip-back design.

I10230 Height Adjustable Armrest Assembly PS - No Charge No ChargeAdjustable in height, with a flip-back design. No charge if ordering power tilt.


Select Options:

I10290 PS Armrest Pads - 10.5"L x 2"W (Pair) No ChargeI10291 PS Armrest Pads - 14"L x 2"W (Pair) No ChargeI10292 Waterfall Armrest Pad for PS - 13.5"L x 3"W (Pair) 79.00I10168 Omit Armrest Pads No ChargeI10166 Corpus Armrest Pad Adapter Brackets 50.00

Must be picked if ordering Corpus armrest pads.I10208 Corpus Armrest Pad 4"x10" Left Leatherette 92.00I10209 Corpus Armrest Pad 4"x12" Left Leatherette 92.00I10210 Corpus Armrest Pad 4"x14" Left Leatherette 92.00I10211 Corpus Armrest Pad 4"x16" Left Leatherette 92.00I10212 Corpus Armrest Pad 4"x10" Right Leatherette 92.00I10213 Corpus Armrest Pad 4"x12" Right Leatherette 92.00I10214 Corpus Armrest Pad 4"x14" Right Leatherette 92.00I10215 Corpus Armrest Pad 4"x16" Right Leatherette 92.00I10169 Armrest Side Support Right Inner 142.00

Will limit the armrest from flipping back. For Corpus Armrest Pads only.I10170 Armrest Side Support Left Inner 142.00

Will limit the armrests from flipping back. For Corpus Armrest Pads only.I101261-99-0 Armrest Side Support Right Outer 142.00


For Corpus Armrest Pads only.

Legrest Options


Required Items

Page 6 of 10Rev 2009-4 8/24/2009 3:07:09PM



Required Items

I10172 70 Degree Swing Away Legrests (Pair) 199.00I10231 70 Degree Swing Away Legrests (Pair) No Charge

No charge if ordering Power Tilt.I10316 Aeron Legrest Assembly for PS Seat 315.00

90° Legrest Hanger with Manual Adjustment Legrest Elevation. Price includes Corpus Style, AngleAdjustable, Two Piece Footplates.


Required Items

I10173 Footplates (Pair), Standard Small No ChargeI10174 Footplates (Pair), Standard Large No Charge

Not available with 16" seat width.I10175 Small Footplates, Multi - Axis Adjustable, Aluminum 195.00 K0108I10176 Large Footplates, Multi - Axis Adjustable, Aluminum 195.00 K0108

Cannot be ordered with 16" or 18" seat widths.


Select Options:

I10177 Heel Loops 90.00 E0951Not available with Aeron Legrest Assembly. (I10316).

I10197 Calf Supports Leatherette No ChargeNot available with lower leg lengths of 10" or less.

I10104 Calf Supports for Aeron Legrest Assembly - PS No Charge E0995Not available with lower leg lengths of 10" or less. Can be ordered only with Aeron LegrestAssembly for PS Seat (PN: I10316).

Accessories


Select Options:

I10401 Bodypoint Non-Padded Hip Belt, PS - Medium No ChargeI10406 Bodypoint Padded Hip Belt PS (C300) - Medium 124.00 K0108I10403 Bodypoint Non-Padded Hip Belt, PS - Large 93.00 K0108I10409 Bodypoint Padded Hip Belt PS - Large 155.00 K0108I10199 Headrest-Removable Leatherette 263.00 E0955

Must also select PN I10552.I103460-99-0 UT Ergo Headrest w/ Black Fabric Cover 292.00 E0955

Must also select PN I10552.I10180 Universal Headrest Adapter 197.00 K0108

Will be sent as part if ordering sling back upholstery.I10552 Adj Removable - Headrest Hardware (1 Each) 212.00 E1028I102059-99-0 Medical Necessities Bag 265.00

Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00I10179 Back Pack Clips Carabiner Style 75.00

Will be sent as part if ordering sling back upholstery.I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950

Must also select PN I10556.I10556 Adj Removable - Tray Hardware (1 Each) 212.00 E1028I101964-99-0 Oxygen Holder for PS or Corpus Seat 224.00


Page 7 of 10Rev 2009-4 8/24/2009 3:07:09PM



Select Options:




Required Items

















Select Options:

I10076 Right Side Mount For Joystick No ChargeI10077 Left Side Mount For Joystick No ChargeI10074 Right Side Mount For Omni No Charge

Page 8 of 10Rev 2009-4 8/24/2009 3:07:09PM



Select Options:

I10075 Left Side Mount For Omni No ChargeI10078 Mount Seat Control Panel on Right No ChargeI10079 Mount Seat Control Panel on Left No ChargeI10080 Mount Seat Control Panel on Backrest No Charge



Required Items



Required Items



Required Items






Select Options:


Page 9 of 10Rev 2009-4 8/24/2009 3:07:09PM






Signed:

Printed Name:

Title:

Date:


Page 10 of 10Rev 2009-4 8/24/2009 3:07:09PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:




Select Options:

I103262-99-0 C350 Corpus 5mph - C350 PS0 6,595.00 K0848Price Includes: RWD C350 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Basic Controller Set Up with 5mph Motor Programming, Tie-DownHardware for Strap Systems, Anti-Tippers, Charger, Flat Free Tires, and Standard BodypointPositioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I10414 C350 Corpus 5mph - C350 PS1 6,595.00 K0856Price Includes: RWD C350 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller Set Up with 5mph Motor Programming, Tie-Down Hardwarefor Strap Systems, Anti-Tippers, Charger, Flat Free Tires, and Standard Bodypoint Positioning Belt.Must Choose Flat Free or Pneumatic Tires Below.

I10415 C350 Corpus 5mph - C350 PS2 6,595.00 K0861Price Includes: RWD C350 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, 5mph Motor Programming, Tie-Down Hardware for Strap Systems,Anti-Tippers, Charger, Flat Free Tires, and Standard Bodypoint Positioning Belt. Must Choose FlatFree or Pneumatic Tires Below.

I10604 6.5mph High Speed Upgrade Package - C350 1,380.00Upgrade option for Group 3 C350 Power Base. This option is only available on C350 Power Baseswith R-net Electronics.

I10416 C350 Corpus 6.5mph - C350 HS PS2 7,975.00 K0884Price Includes: RWD C350 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, 6.5mph Motor Programming, Tie-Down Hardware for StrapSystems, Anti-Tippers, Flat Free Tires, and Standard Bodypoint Positioning Belt. Must Choose FlatFree or Pneumatic Tires Below.


Required Items



Required Items

I103532-99-0 C350 Shroud Vintage Wine No ChargeI103533-99-0 C350 Shroud Crystal Blue No ChargeI103529-99-0 C350 Shroud Onyx Black No ChargeI103530-99-0 C350 Shroud Platinum Silver No ChargeI103531-99-0 C350 Shroud Extreme Yellow No Charge


Required Items



Base Options


Required Items

I103524-99-0 Power Adjustable Seat Height, 8" Travel 2,395.00 E2300To assist in transfers and improve access for function.



Select Options:

IM34 SLDG Batteries - Group 34, 12V 60 Amp Hours, Installed 762.00 K0108

Page 2 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:

I103496-99-0 Light Kit for C350 955.00Cannot be ordered with VR2 Electronics.


Permolock


Select Options:


I10609 Permolock C3 Dual Locking Pin Kit - C350 595.00This kit includes two spring loaded pins that will be mounted underneath the base of thewheelchair. These pins are spring loaded so they push into the wheelchair base when an obstacleis encountered. The kit also includes a set of reinforced braces must be installed whenever thespring loaded pins are mounted in a C350 Base.

Joystick Options


Required Items



Select Options:





Page 3 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:












Seating System


Required Items

The Following Seats Include (Must Select One)Corpus Seat Frame, Solid Backrest with Manual Adjustable Recline Angle, Height AdjustableArmrest Assembly, Solid Seat Pan, Legrest Assembly with Adjustable Elevation. Weight Limit300lbs.

I10239 Corpus Seat without Power Tilt or Power Recline 5,595.00 K0108I103525-99-0 Corpus Seat w/ 45° CG Pwr Tilt & Manual Recline 6,195.00 E1002I103528-99-0 Corpus Seat w/ 150° Power Recline 6,650.00 E1004I10417 Corpus Seat w/ 45° CG Pwr Tilt & 150° Pwr Recline 10,195.00 E1007



Select Options:


Page 4 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:










Backrest Options


Required Items


I101853-99-0 Ergo Back Fixed 14" W x 21" H - Leatherette 837.00 E2620I101863-99-0 Ergo Back Fixed 14"W x 26.5" High - Leatherette 837.00 E2620I101854-99-0 Ergo Back Sliding 16"W x 21"H - Leatherette 837.00 E2620I101861-99-0 Ergo Back Sliding 16"W x 26.5" H - Leatherette 837.00 E2620I101855-99-0 Ergo Back Sliding 18"W x 21"H - Leatherette 837.00 E2620I101862-99-0 Ergo Back Sliding 18"W x 26.5"H - Leatherette 837.00 E2620I305510-00-90-0 Ergo Back Fixed Tall 16"W x 29.5"H - Leatherette 837.00 E2620I10455 Ergo Back Fixed 14" W x 21" H - Black Mesh 859.00 E2620I10456 Ergo Back Fixed 14"W x 26.5" High - Black Mesh 859.00 E2620I10457 Ergo Back Sliding 16"W x 21"H - Black Mesh 859.00 E2620I10458 Ergo Back Sliding 16"W x 26.5" H - Black Mesh 859.00 E2620I10459 Ergo Back Sliding 18"W x 21"H - Black Mesh 859.00 E2620I10460 Ergo Back Sliding 18"W x 26.5"H - Black Mesh 859.00 E2620I10004 Rectangular Backrest 16"W - Plastic, Fixed 1,119.00

Choose backrest height from seat pan: 19"-29" ___"

Page 5 of 12Rev 2009-4 8/24/2009 3:07:33PM



Required Items

I10005 Rectangular Back 18"W - Metal Fixed 1,307.00Choose backrest height from seat pan: 19"-29" ___"

I10240 Solid Back 16"W X 21"H No ChargeStandard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.

I10130 Solid Back 16"W x 26.5"H No ChargeStandard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.

I10241 Solid Back 18"W x 21"H No ChargeStandard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.


I10111 Tubular Backrest Frame Corpus, 16" Wide 357.00Backrest canes to mount aftermarket backrest systems. For tilt only systems. Measurementbetween the armrests is 17.5". Seat pan to top of canes is 22".



Select Options:








Seat Sizing


Required Items

I100684-99-0 Corpus Seat 17"W x 16"D No ChargeI100689-99-0 Corpus Seat 17"W x 18"D No ChargeI100695-99-0 Corpus Seat 17"W x 20"D No ChargeI100720-99-0 Corpus Seat 17"W x 22"D No ChargeI100690-99-0 Corpus Seat 19"W x 18"D No ChargeI100696-99-0 Corpus Seat 19"W x 20"D No ChargeI100721-99-0 Corpus Seat 19"W x 22"D No ChargeI10007 Special Seat Size 21"W x 18"D No ChargeI10008 Special Seat Size 21"W x 20"D No ChargeI10009 Special Seat Size 21"W x 22"D No Charge

Page 6 of 12Rev 2009-4 8/24/2009 3:07:33PM



Required Items

I10010 Special Seat Size 23"W x 18"D No ChargeI10011 Special Seat Size 23"W x 20"D No ChargeI10012 Special Seat Size 23"W x 22"D No Charge


Select Options:



Armrest Options


Required Items



Required Items



Select Options:





I304968-99-0 Corpus Armbar for 18" Btw the Arms - Installed 265.00I10001 Corpus Armbar for 20" Btw the Arms - Installed 295.00I100523-99-0 Armrest Height Ext (+2") 125.00IARMADAP1" Arm Trough Adaptor 1" Pair 274.00


Page 7 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:










Legrest Options


Required Items



Required Items

I102051-99-0 Legrest Assm. 2pc Narrow Footplates (Complete) No Charge


Select Options:




I10024 Leg Length Ext Kit (pair) 16-21" From Seat Pan 275.00Standard length is 11" - 16" from seat pan to footplate. Set legs at ______" from top of seat pan tofootplate.

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium 113.00 K0108I10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108I100600-99-0 Positioning Belt Retractable Long 255.00 K0108

Page 8 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:

I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955Must also select PN I10552. This part consists of a leatherette headrest pad (10"W x 5"T) with a10"L slotted, curved mounting bracket.
























Page 9 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:












Required Items











Page 10 of 12Rev 2009-4 8/24/2009 3:07:33PM



Required Items







Select Options:




Required Items



Required Items



Required Items






Select Options:


Page 11 of 12Rev 2009-4 8/24/2009 3:07:33PM



Select Options:







Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 3:07:33PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:




Select Options:

I10475 C400 Base Corpus R-net - C400 PS0 8,995.00 K0848Price Includes: FWD C400 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Basic Controller, Tie-Down Hardware for Strap Systems, Charger, FlatFree Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I10476 C400 Base Corpus R-net - C400 PS1 8,995.00 K0856Price Includes: FWD C400 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Charger, Flat FreeTires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I103259-99-0 C400 Base Corpus R-net - C400 PS2 8,995.00 K0861Price Includes: FWD C400 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items

I102190-99-0 C400 Shroud Vintage Wine No ChargeI103957-99-0 C400 Shroud Onyx Black No ChargeI102194-99-0 C400 Shroud Crystal Blue No ChargeI102191-99-0 C400 Shroud Metallic Charcoal Gray No ChargeI102192-99-0 C400 Shroud Green Metallic No ChargeI103958-99-0 C400 Shroud Extreme Yellow No Charge


Required Items



Base Options


Required Items

I103865-99-0 Power Adjustable Seat Height, 8" Travel (R-net) 2,595.00 E2300To assist in transfers and improve access for function.



Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I102210-99-0 Anti-Tippers for C400/C500 399.00I103635-99-0 Light Kit, R-net, C400/C500 955.00I100570-99-0 Seat Stabilizer No Charge I103241-99-0 Articulating Vent Tray for C400/C500 1,295.00 E1030

If selecting this part, you MUST also pick: PN I104082-99-0 - ESP Unit. Fits an LP10 Sized Ventand a Group 34 Battery. Cannot be ordered with backrest height less than 26.5", a tubular back, ora 13" seat depth. Customization may be required if ordered with any of the following itemsCo-Pilot, any standard attendant control, push handles, or an oxygen holder. Only available withexpandable controllers (R-net Electronics.)

Page 2 of 12Rev 2009-4 8/24/2009 3:08:16PM



Select Options:

I104082-99-0 R-net ESP w C400/C500 Mounting Bracket 1,250.00 K0108MUST be selected if ordering any ventilator tray (I102769-99-0, I103241-99-0, or I102768-99-0).Recommended item with switched drive inputs for improved tracking.


Permolock


Select Options:

I102843-99-0 Permolock C Kit - COMPLETE 2,485.00Includes: Locking Base, Plunger, and Manual Release Handle. The Locking Base must beinstalled by a NMEDA Dealer. Please provide the NMEDA Dealer Name & Address where thelocking Base will ship to. .NAME:_____________________________________________ . . .. ADDR:_____________________________________________

I102842-99-0 Plunger ONLY for Permolock C 1,008.00Price Includes: Plunger only. This item may be purchased by any Permobil Inc or NMEDA certifieddealer. The standard mounting position for the button to control the plunger is at the end of thearmrest pad, opposite the joystick.

Joystick Options


Required Items



Select Options:





Page 3 of 12Rev 2009-4 8/24/2009 3:08:16PM



Select Options:












Seating System


Required Items

The Seating Systems Listed Below Include:Corpus Seat Frame, Solid Backrest (Standard Size) with Adjustable Recline Angle, HeightAdjustable Armrest Assembly, Solid Seat Pan (17"w x 18"d), Legrest Assembly with AdjustableElevation. Weight Limit 250lbs (310 lbs/ HD Package).

I10025 Corpus Seat without Power Tilt or Power Recline 5,595.00 K0108I10479 Corpus Seat w/ 45° Power Tilt & Manual Recline 6,340.00 E1002

NOTE: If clients weight is between 266-310lbs, the 45° Power Tilt Kit will be limited to a MAXIMUMof 30° of posterior tilt.

I10480 Corpus Seat w/ 120° Power Recline 6,872.00 E1004Includes power recline actuator mounted behind the back with a reinforced mounting system.

I10481 Corpus Seat w/ 150° Power Recline 6,872.00 E1004Includes a side mounted powered recline actuator. NOTE: This configuration is not available forusers who weigh between 251-310lbs.

I10482 Corpus Seat w/ 175° Power Recline 7,450.00 E1004Includes a side mounted power recline actuator. This configuration cannot be selected with seatseat depths less than 18", and is not available for users who weigh between 251-310lbs.

Page 4 of 12Rev 2009-4 8/24/2009 3:08:16PM



Required Items

I10486 Corpus Seat w/ 45° Power Tilt & 120° Power Recline 10,995.00 E1007Includes power recline actuator mounted behind the back with a reinforced mounting system.NOTE: If clients weight is between 266-310lbs, the 45° Power Tilt Kit will be limited to a MAXIMUMof 30° of posterior tilt.

I10487 Corpus Seat w/ 45° Power Tilt & 150° Power Recline 10,350.00 E1007Includes a side mounted powered recline actuator. NOTE: This configuration is not available forusers who weigh between 251-310lbs.

I10488 Corpus Seat w/ 45° Power Tilt & 175° Power Recline 10,995.00 E1007Includes a side mounted power recline actuator. This configuration cannot be selected with seatseat depths less than 18", and is not available for users who weigh between 251-310lbs.



Select Options:

I10495 Heavy Duty Package, R-net C400/C500 Corpus 2,545.00This item MUST be selected for any user between 251-310lbs. Available with the following seatingsystems: I10480 & I10486. Includes: Anti-tippers, Heavy Duty Arm Supports, & Heavy Duty Mountfor Recline. NOTE: For users between 266-310lbs: (1) The 45° Power Tilt Kit will be limited to aMAXIMUM of 30° of posterior tilt, (2) The overall back angle CANNOT exceed 150° in any seatpostion, and (3) driving will be inhibited if the seat elevator is raised.

I10013 Mount Seat Frame in Tall Position 317.00I10418 Single Seat Function Control Switch for R-net No Charge

Please choose either Push Buttons or Toggle Switches below.I10419 Single Seat Function Control Kit for R-net 1,478.00 E2310

For operation of a single seat function through the wheelchair electronics via the drive controland/or ICS Switchbox. Order with R-net Controller or remote joystick options. Please indicatebelow if you want push buttons or toggles on the Seat Function Control Kit.









Page 5 of 12Rev 2009-4 8/24/2009 3:08:15PM



Select Options:

I10497 Memory Seat Program, C400 or C500 Corpus w R-net 98.00If this is selected, the chair will be programmed to allow the user to store and save up to 3 differentmemory seat positions. On the C400/C500 Corpus and Lowrider, the following seat functions arecapable of remembering a seat position: Power Tilt, Power Recline, & Power Legs. The Power AdjSeat Height Function is NOT capable of recalling a saved memory seat position. Please refer tothe Corpus Seat Owner's Manual for more information on saving and recalling memory seatpositions.

Backrest Options


Required Items












Select Options:



Page 6 of 12Rev 2009-4 8/24/2009 3:08:16PM



Select Options:






Seat Sizing


Required Items

I100681-99-0 Corpus Seat 17"W x 14"D No ChargeAn additional custom charge will be applied if ordering an 18" wide sliding backrest with this seatsize (17" x 14").

I100684-99-0 Corpus Seat 17"W x 16"D No ChargeI100689-99-0 Corpus Seat 17"W x 18"D No ChargeI100695-99-0 Corpus Seat 17"W x 20"D No ChargeI100720-99-0 Corpus Seat 17"W x 22"D No ChargeI100690-99-0 Corpus Seat 19"W x 18"D No ChargeI100696-99-0 Corpus Seat 19"W x 20"D No ChargeI100721-99-0 Corpus Seat 19"W x 22"D No ChargeI10007 Special Seat Size 21"W x 18"D No ChargeI10008 Special Seat Size 21"W x 20"D No ChargeI10009 Special Seat Size 21"W x 22"D No ChargeI10010 Special Seat Size 23"W x 18"D No ChargeI10011 Special Seat Size 23"W x 20"D No ChargeI10012 Special Seat Size 23"W x 22"D No Charge


Select Options:



Armrest Options


Required Items

I103339-99-0 4"x10" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103341-99-0 4"x12" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103343-99-0 4"x14" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103345-99-0 4"x16" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103331-99-0 4"x10" Corpus Arm Right - Dual Taper, Black Fabric No Charge

Page 7 of 12Rev 2009-4 8/24/2009 3:08:16PM



Required Items

I103333-99-0 4"x12" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103335-99-0 4"x14" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103337-99-0 4"x16" Corpus Arm Right - Dual Taper, Black Fabric No Charge


Required Items



Select Options:
















Legrest Options

Page 8 of 12Rev 2009-4 8/24/2009 3:08:16PM



Required Items

I103867-99-0 Power Articulating Center Mount Elevating Legrest 2,749.00 K0108I102212-99-0 Manual Adjustment Legrest Elevation No Charge

Includes Calf Supports.


Select Options:






I10006 3" Width Between Two- Piece Footplates 495.00Not available if chair has anti-tips and lower leg length is greater than 14" (measured from seat panto top of footplate.)

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10405 Bodypoint Padded Hip Belt UniTrack (N/C) - Medium No ChargeI10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108I100600-99-0 Positioning Belt Retractable Long 255.00 K0108I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955











Page 9 of 12Rev 2009-4 8/24/2009 3:08:16PM



Select Options:











Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00I101500-99-0 Essentials Carrier for Chassis 379.00I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950













Page 10 of 12Rev 2009-4 8/24/2009 3:08:16PM




Required Items

















Select Options:


Page 11 of 12Rev 2009-4 8/24/2009 3:08:16PM




Required Items



Required Items



Required Items

(4) OMNI PLUS CONTROL MODULE (REQUIRED)ID51154IR Omni Control Module for R-net w/ Infrared 1,470.00

Please specify which type of alternative drive input you will be using if not ordering the input devicefrom Permobil. Input Device: ___________________________




Select Options:







Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 3:08:16PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:




Select Options:

I10475 C400 Base Corpus R-net - C400 PS0 8,995.00 K0848Price Includes: FWD C400 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Basic Controller, Tie-Down Hardware for Strap Systems, Charger, FlatFree Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I10476 C400 Base Corpus R-net - C400 PS1 8,995.00 K0856Price Includes: FWD C400 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Charger, Flat FreeTires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I103259-99-0 C400 Base Corpus R-net - C400 PS2 8,995.00 K0861Price Includes: FWD C400 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items



Required Items



Base Options


Required Items




Select Options:



Page 2 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:



Joystick Options


Required Items



Select Options:



Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.I103814-99-0 Compact Advanced Joystick for R-net 605.00 E2373

Compact sized joystick that does not contain an LCD Display. This is an expandable/remotejoystick used with multiple power option bases or as an upgrade for no power option or singlepower option bases. Must order expandable controller (PN: I10411) with this part. Contains twomono jacks for mode & on/off. When ordering the Compact Advanced Joystick, the ICS Switchboxmust be mounted to the opposite armrests or off the backrest in order to fully access themonojacks.





Page 3 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:









Seating System


Required Items

The Seating Systems Listed Below Include:Corpus Seat Frame with 1" Depth Adjustments from 13" - 18" ( & up to 22" Deep with StandardCorpus Seat Frame) Back Frame with Adjustable Recline Angle, Reclining Armrest Assembly,Solid Seat Pan, Legrest Assembly with Adjustable Legrest Elevation, Weight Limit 165 lbs for SeatDepths Less Than 16". Weight Limit of 250 lbs for Seat Depths of 16" or Greater.

I10491 Corpus Junior Seat w/o Pwr Tilt or Pwr Recline 5,689.00 K0108Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" Increments

I10492 Corpus Junior Seat w/ 45° Pwr Tilt & Manual Recline 6,830.00 E1002Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" Increments

I10493 Corpus Junior Seat w 150° Power Recline 7,356.00 E1004Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" Increments

I10494 Corpus Jr Seat w 45° Pwr Tilt & 150° Pwr Recline 10,695.00 E1007Includes:Solid Backrest, Height Adjustable Armrest and Seat Sizes Adjustable in 1" Increments



Select Options:



Page 4 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:










Backrest Options


Required Items


I101853-99-0 Ergo Back Fixed 14" W x 21" H - Leatherette 837.00 E2620I101863-99-0 Ergo Back Fixed 14"W x 26.5" High - Leatherette 837.00 E2620I101854-99-0 Ergo Back Sliding 16"W x 21"H - Leatherette 837.00 E2620I101861-99-0 Ergo Back Sliding 16"W x 26.5" H - Leatherette 837.00 E2620I10455 Ergo Back Fixed 14" W x 21" H - Black Mesh 859.00 E2620I10456 Ergo Back Fixed 14"W x 26.5" High - Black Mesh 859.00 E2620I10457 Ergo Back Sliding 16"W x 21"H - Black Mesh 859.00 E2620I10458 Ergo Back Sliding 16"W x 26.5" H - Black Mesh 859.00 E2620I10004 Rectangular Backrest 16"W - Plastic, Fixed 1,119.00



Page 5 of 12Rev 2009-4 8/24/2009 3:08:38PM



Required Items


I10111 Tubular Backrest Frame Corpus, 16" Wide 357.00Backrest canes to mount aftermarket backrest systems. For tilt only systems. Measurementbetween the armrests is 17.5". Seat pan to top of canes is 22".


Select Options:







I10320 Omit Ergonomic Backrest Cushion No ChargeI10278 Notch Backrest Cushion for Lateral Supports 185.00

Backrest Cushion will be notched 2" in on either side to allow for closer adjustment of trunksupports.

Seat Sizing


Required Items

I10264 Corpus Junior Seat Width - Standard No ChargeCorpus seat frame is 17" wide at the outside and 15" wide between the seat rails. Actual hip widthcan be accommodated with size appropriate cushion and/or hip guides.


Required Items

I10265 Corpus Junior Seat 13" Deep No ChargeI10266 Corpus Junior Seat 14" Deep No ChargeI10267 Corpus Junior Seat 15" Deep No ChargeI10268 Corpus Junior Seat 16" Deep No ChargeI10269 Corpus Junior Seat 17" Deep No ChargeI10270 Corpus Junior Seat 18" Deep No Charge


Select Options:



Page 6 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:


Armrest Options


Required Items

I103339-99-0 4"x10" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103341-99-0 4"x12" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103343-99-0 4"x14" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103331-99-0 4"x10" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103333-99-0 4"x12" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103335-99-0 4"x14" Corpus Arm Right - Dual Taper, Black Fabric No Charge


Required Items

I103338-99-0 4"x10" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103340-99-0 4"x12" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103342-99-0 4"x14" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103330-99-0 4"x10" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103332-99-0 4"x12" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103334-99-0 4"x14" Corpus Arm Left - Dual Taper, Black Fabric No Charge


Select Options:












Recommend 2" wider width between the armrest to ensure armrests will flip-up.I10285 Mount Corpus Armrest Pads On Inside of Bracket No Charge


Page 7 of 12Rev 2009-4 8/24/2009 3:08:38PM


Legrest Options


Required Items




Select Options:




I100561-99-0 Legrest Assm. 1pc Footplate (Complete) 395.00I102051-99-0 Legrest Assm. 2pc Narrow Footplates (Complete) No ChargeI10006 3" Width Between Two- Piece Footplates 495.00

Not available if chair has anti-tips and lower leg length is greater than 14" (measured from seat panto top of footplate.)

I10271 Corpus Junior Lower Leg Length No ChargeModification to allow for lower leg lengths of 8" - 10". Standard length is 11"-15". Measurement istaken from seat pan to the top of the footplates. Please specify lower leg length measurement ininches: ____________


Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10405 Bodypoint Padded Hip Belt UniTrack (N/C) - Medium No ChargeI10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108I100749-99-0 Miniflex Headrest Removable - Leatherette 263.00 E0955

Must also select PN I10552.I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955







8"W x 8"T Flat Pad. Must also select PN I10553.

Page 8 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:

I10553 Adj Removable - Amp Support Hardware (1 Each) 212.00 E1028Please indicate if you would like the amputation support mounted on the right or left side of the seatframe: Mount Amp Suppt on Right: ___________ Mount Amp Suppt on Left: ___________






I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I10272 Fixed Trunk Supports Jr Corpus - Leatherette 246.00 E0956







Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00I101500-99-0 Essentials Carrier for Chassis 379.00ISH212 BP Shoulder Harness Medium, Front Pull 196.00 E0960

This item will be sent as a part with the wheelchair. It will not be installed.I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950









Page 9 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:




Required Items

















Select Options:

I10076 Right Side Mount For Joystick No ChargeI10077 Left Side Mount For Joystick No ChargeI10074 Right Side Mount For Omni No Charge

Page 10 of 12Rev 2009-4 8/24/2009 3:08:38PM



Select Options:

I10075 Left Side Mount For Omni No ChargeI10078 Mount Seat Control Panel on Right No ChargeI10079 Mount Seat Control Panel on Left No ChargeI10080 Mount Seat Control Panel on Backrest No Charge



Required Items



Required Items



Required Items






Select Options:


Page 11 of 12Rev 2009-4 8/24/2009 3:08:38PM






Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 3:08:38PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC400 Lowrider



Select Options:

I10498 C400 Base Lowrider R-net - C400 PS0 10,995.00 K0848Price Includes: FWD C400 Power Base Set Up For No Power Seat Functions, Shock AbsorbingSuspension System, R-net Controller, Tie-Down Hardware for Strap Systems, Charger, 16.5" Seatto Floor Height, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free orPneumatic Tires Below.

I10499 C400 Base Lowrider R-net - C400 PS1 10,999.00 K0856Price Includes: FWD C400 Power Base Set Up For One Power Seat Function, Shock AbsorbingSuspension System, R-net Controller, Tie Down Hardware for Strap Systems, Charger, 16.5" Seatto Floor Height, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free orPneumatic Tires Below.

I104019-99-0 C400 Base Lowrider R-net - C400 PS2 10,999.00 K0861Price Includes: FWD C400 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, 16.5" Seat toFloor Height, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or PneumaticTires Below.


Required Items



Required Items



Required Items



Base Options


Required Items

I102087-99-0 Seat Tube Fixed No ChargeI103972-99-0 Power Adjustable Seat Height 6" Travel 2,995.00 E2300



Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I102210-99-0 Anti-Tippers for C400/C500 399.00I103635-99-0 Light Kit, R-net, C400/C500 955.00ID51113 Programming Key for R-net - Permobil Version 435.00

Permolock

Page 2 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:



Joystick Options


Required Items



Select Options:


Please indicate which armrest to mount midline below.I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No ChargeI103544-99-0 R-net Remote Joystick 530.00

Must order expandable controller (PN: I10411) with this part. Comes standard w/ mono jacks.ID51040 R-net Remote Joystick w/ Toggle Switches 605.00

Expandable/remote joystick with toggle switches. Used with multiple power option bases or as anupgrade for no power option or single power option bases. Must order expandable controller (PN:I10411) with this part.





Page 3 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:







Seating System


Required Items


I10489 Lowrider Seat w/20° Power Tilt & Manual Recline 6,995.00 E1002Includes a manual recline actuator mounted behind the backrest.

I10490 Lowrider Seat w/20° Power Tilt & 120° Power Recline 10,995.00 E1007Includes a powered recline actuator mounted behind the backrest.



Select Options:

I10496 Heavy Duty Package Lowrider w/ R-net 2,545.00Includes: Anti-tippers, heavy duty armrest supports, drive inhibit for power adjustable seat heightand heavy duty mount for recline. This is a required option for users between 251-310lbs.




I102798-99-0 Push Buttons on Seat Function Control Kit No ChargeI102799-99-0 Toggle Switches on Seat Function Control Kit 245.00

Page 4 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:

I103469-99-0 Mount ICS Switchbox onto R-net Joystick Bracket No ChargeICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item isselected, the ICS Switchbox will swing away with the Joystick Module.







Backrest Options


Required Items






Page 5 of 12Rev 2009-4 8/24/2009 3:09:29PM



Required Items





Select Options:








Seat Sizing


Required Items




Select Options:

Page 6 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:



Armrest Options


Required Items



Required Items



Select Options:









I100671-99-0 Armrest Pouch-Right 190.00I100672-99-0 Armrest Pouch-Left 190.00

Page 7 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:

I101261-99-0 Armrest Side Support Right Outer 142.00For Corpus Armrest Pads only.

I101262-99-0 Armrest Side Support Left Outer 142.00For Corpus Armrest Pads only.

I101263-99-0 Armrest Side Support Right Inner 142.00Recommend 2" wider width between the armrest to ensure armrests will flip-up.

I101264-99-0 Armrest Side Support Left Inner 142.00Recommend 2" wider width between the armrest to ensure armrests will flip-up.

I101510-99-0 Armrest Supports HD 486.00Cannot be ordered with 175 degree power recline seating systems. (I10482, I10485, I10488).

Legrest Options


Required Items


Includes calf supports.


Select Options:




I101276-99-0 Legrest Assm. 2pc Footplates (Complete) No ChargeI101277-99-0 Legrest Assm. 1pc Footplate 395.00I10006 3" Width Between Two- Piece Footplates 495.00


Accessories


Select Options:






Page 8 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:

























Page 9 of 12Rev 2009-4 8/24/2009 3:09:29PM



Select Options:







Required Items














Requires Omni Control Module. Cannot use this part with an Input Module.

Page 10 of 12Rev 2009-4 8/24/2009 3:09:29PM



Required Items

I10574 Sip & Puff System with Fiber Optic Opti-Stop 1,929.00 E2325,E2326Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tubekit.


Select Options:




Required Items



Required Items



Required Items






Select Options:


Page 11 of 12Rev 2009-4 8/24/2009 3:09:29PM






Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 3:09:29PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC400 VS Junior



Select Options:

I104057-99-0 C400 Base VS Jr R-net - C400 PS2 9,995.00 K0861Price Includes: FWD C400 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items



Required Items



Base Options


Required Items

I103547-99-0 Power Adjustable Seat Height 10" Travel - C400 2,495.00 E2300This item must be selected. The lowest seat to floor height may be 18.5", 19.5" or 20.5"; however,this is a setting that must be adjusted prior to chair shipping from Permobil. Please indicate belowwhat seat to floor height you would like.


Required Items

I10504 Set Seat Height at 18.5" No ChargeI10505 Set Seat Height at 19.5" No ChargeI10506 Set Seat Height at 20.5" No Charge


Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I103635-99-0 Light Kit, R-net, C400/C500 955.00I309297-28-0 Anti-Tippers for C400 VS Jr & C500 VS 399.00

Anti-Tippers are required for any user weight above 220lbs. They are included in the High SpeedPackage for the C500 VS Base (I104060-99-0).



Page 2 of 11Rev 2009-4 8/24/2009 3:09:56PM


Permolock


Select Options:



I103242-99-0 3.6m Plunger Sw Ext Cable for VS with Permolock C No ChargeThis Cable MUST be selected when a Permolock C is ordered with a VS seating system.

Joystick Options


Required Items



Select Options:







Page 3 of 11Rev 2009-4 8/24/2009 3:09:56PM



Select Options:






I104002-99-0 Co-Pilot Attendant Control, VS R-net 4,175.00 E2331Custom charge may apply if ordering a backrest height of 21" or Lower.



Seating System


Required Items

VS Jr Seat Note:You must select both part numbers listed below. The combined price includes: Seat Frame withAdjustable Depth, Fixed Chest Bar, Solid Seat Pan, Solid Backrest, and Height AdjustableArmrests. The weight capacity of the VS Jr Seat is 165 lbs.

I10508 Power Tilt & Power Recline - VS Junior Seat 9,855.00 E1007This item must be selected. Includes 25° Power Tilt & 175° Power Recline.

I104133-99-0 Power Standing Function - VS Junior Seat 4,295.00 E2301This item must be selected.



Required Items



Select Options:



Page 4 of 11Rev 2009-4 8/24/2009 3:09:56PM



Select Options:



I103470-99-0 Mount ICS Switchbox on Backrest 125.00I104746-99-0 Remote Stop System - R-net, Pilot+ 985.00

Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on thewheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be usedtogether. Custom charge may be required if ordering with a low backrest height or a pediatricwheelchair. If ordering Remote Stop System with a K450, push handles must also be selected.

Backrest Options


Required Items


I100794-99-0 Ergo Back 14"W x 26.5"T - Leatherette, For Stander 837.00 E2620I100795-99-0 Ergo Back 16"W x 26.5"T - Leatherette, For Stander 837.00 E2620I100796-99-0 Ergo Back 18"W x 26.5"T - Leatherette, For Stander 837.00 E2620I10464 Ergo Back 14"W x 26.5"T - Black Mesh, For Stander 847.00 E2620I10465 Ergo Back 16"W x 26.5"T - Black Mesh, For Stander 847.00 E2620I10466 Ergo Back 18"W x 26.5"T - Black Mesh, For Stander 847.00 E2620I100434-99-0 Omit Backrest Kit 14" W Between Armrests No ChargeI100435-99-0 Omit Backrest Kit 16" W Between Armrests No ChargeI100436-99-0 Omit Backrest Kit 18" W Between Armrests No ChargeI10242 Solid Back for Standing Seat 16"W x 26.5"H No Charge

Standard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.I10243 Solid Back for Standing Seat - 18"W x 26.5"H No Charge

Standard Option with Tilt and/or Recline Systems. Includes Leatherette back cushion ONLY.


Select Options:

I10047 21" Back Height (Ergo Only) No ChargeI10014 Custom Backrest Height ______" 625.00

Backrest height measured from seat pan and cannot be lower than 19". Price in addition to abovebackrest.




I101101-99-0 Backrest Reinforcement 260.00I1824006 Sliding Backrest Kit for VS & VS Jr Seats 1,270.00

Provides 4" of mechanical shear reduction. Custom charge may be applied if ordering this item withany backrest shorter than 26.5".

Page 5 of 11Rev 2009-4 8/24/2009 3:09:56PM


Seat Sizing


Required Items

I103368-99-0 VS Jr Seat 17"W x 14"D No ChargeI103369-99-0 VS Jr Seat 17"W x 15"D No ChargeI103370-99-0 VS Jr Seat 17"W x 16"D No ChargeI103371-99-0 VS Jr Seat 17"W x 17"D No ChargeI103372-99-0 VS Jr Seat 17"W x 18"D No Charge


Select Options:



Armrest Options


Required Items



Required Items



Required Items

I101003-99-0 Armrest Mount High No ChargeRange of adjustment in high position is 11" - 13.5" measured from the seat pan to the top of thearmrest pad.



Select Options:

I10016 Height Adjustable Armrest Assembly - No Charge No ChargeNo charge with power tilt and/or recline.

I304969-99-0 18" Between Armrests w/ 16" Backrest 265.00I100523-99-0 Armrest Height Ext (+2") 125.00

Page 6 of 11Rev 2009-4 8/24/2009 3:09:56PM



Select Options:








Recommend 2" wider width between the armrest to ensure armrests will flip-up.

Legrest Options


Required Items

I10502 Power Articulating Center Mount Elevating Legrests 2,749.00 K0108This item must be selected.


Required Items

I103351-99-0 Stand and Drive Legrest Assembly - Jr 685.00 This item must be selected.


Required Items

I103353-99-0 Kneeblock Upholstery - Leatherette No ChargeI103352-99-0 Kneeblock Upholstery - Black Mesh 147.00


Select Options:


I103394-99-0 UT Calf Support Kit (J) w Mesh Cover & Adj Hdw - VS No Charge

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10405 Bodypoint Padded Hip Belt UniTrack (N/C) - Medium No ChargeI10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955


Page 7 of 11Rev 2009-4 8/24/2009 3:09:56PM



Select Options:





4.5"W x 3.5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.I103079-99-0 UT Hip Suppt (A) w/ Mesh Cover - Low (Pair) 225.00 E0956

6"W x 5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) 225.00 E0956

6.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I103095-99-0 UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) 225.00 E0956

8"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I102977-99-0 UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) 225.00 E0956

12"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I10272 Fixed Trunk Supports Jr Corpus - Leatherette 246.00 E0956

Must also select PN I10551.I305266-28-90-0 Lateral Supports Std. Leatherette-ErgoBack Only 246.00 E0956



Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I101099-99-0 Chest Bar 14" Adjustable Leatherette 245.00I307649-99-60-0 Chest Bar 14" Adjustable Black Mesh 265.00I101095-99-0 Chest Bar 16" Adjustable Leatherette 245.00I306688-99-60-0 Chest Bar 16" Adjustable, Black Mesh 265.00I101097-99-0 Chest Bar 18" Adjustable Leatherette 245.00I307650-99-60-0 Chest Bar 18" Adjustable Black Mesh 265.00I100978-99-0 Abductor Kit - Leatherette 306.00 E0957

Must also select PN I10555.I10555 Adj Removable - Abductor Hardware (1 Each) 212.00 E1028I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I101100-99-0 Push Handles for Standing Seat 339.00I101473-99-0 Back Pack Clips Carabiner Style 75.00I102059-99-0 Medical Necessities Bag 265.00






Page 8 of 11Rev 2009-4 8/24/2009 3:09:56PM



Select Options:







Required Items

















Select Options:

Page 9 of 11Rev 2009-4 8/24/2009 3:09:56PM



Select Options:




Required Items



Required Items



Required Items






Select Options:


Page 10 of 11Rev 2009-4 8/24/2009 3:09:56PM






Signed:

Printed Name:

Title:

Date:


Page 11 of 11Rev 2009-4 8/24/2009 3:09:56PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:




Select Options:

I103257-99-0 C500 Base Rnet, 5.0mph - C500 PS2 10,795.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I103258-99-0 C500 Base HS Rnet, 6.5mph - C500 PS2 11,945.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, ESP (Enhanced Steering Performance), High Speed Motors, 120Amp Electronics, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires, and StandardPositioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items

I103816-99-0 C500 Shroud Onyx Black No ChargeI102260-99-0 C500 Shroud Vintage Wine No ChargeI102261-99-0 C500 Shroud Crystal Blue No ChargeI102262-99-0 C500 Shroud Metallic Charcoal Gray No ChargeI102263-99-0 C500 Shroud Green Metallic No ChargeI103833-99-0 C500 Shroud Platinum Silver No ChargeI103632-99-0 C500 Shroud Pearl White No Charge


Required Items



Base Options


Required Items




Select Options:



Page 2 of 12Rev 2009-4 8/24/2009 3:10:34PM



Select Options:



Permolock


Select Options:



Joystick Options


Required Items



Select Options:





Page 3 of 12Rev 2009-4 8/24/2009 3:10:34PM



Select Options:



ID51187 R-net Remote Colored JS w/ Speed Pot 875.00ID51190 R-net Remote Color JS w/ Speed Pot & Single Toggle 875.00

Must order expandable controller (PN: I10411) with this part.ID51149 R-net Remote Color Screen JS w/ Toggle Switches 875.00

Must order expandable controller (PN: I10411) with this part.I10411 Expandable Controller - R-net 525.00 E2377

Must be ordered with the expandable/remote joysticks (PN: I10410, I103544-99-0, ID51040,ID51108, ID51042, and I103814-99-0).






Seating System


Required Items


I10025 Corpus Seat without Power Tilt or Power Recline 5,595.00 K0108I10479 Corpus Seat w/ 45° Power Tilt & Manual Recline 6,340.00 E1002

NOTE: If clients weight is between 266-310lbs, the 45° Power Tilt Kit will be limited to a MAXIMUMof 30° of posterior tilt.

I10480 Corpus Seat w/ 120° Power Recline 6,872.00 E1004Includes power recline actuator mounted behind the back with a reinforced mounting system.

I10481 Corpus Seat w/ 150° Power Recline 6,872.00 E1004Includes a side mounted powered recline actuator. NOTE: This configuration is not available forusers who weigh between 251-310lbs.

I10482 Corpus Seat w/ 175° Power Recline 7,450.00 E1004Includes a side mounted power recline actuator. This configuration cannot be selected with seatseat depths less than 18", and is not available for users who weigh between 251-310lbs.

Page 4 of 12Rev 2009-4 8/24/2009 3:10:34PM



Required Items

I10486 Corpus Seat w/ 45° Power Tilt & 120° Power Recline 10,995.00 E1007Includes power recline actuator mounted behind the back with a reinforced mounting system.NOTE: If clients weight is between 266-310lbs, the 45° Power Tilt Kit will be limited to a MAXIMUMof 30° of posterior tilt.

I10487 Corpus Seat w/ 45° Power Tilt & 150° Power Recline 10,350.00 E1007Includes a side mounted powered recline actuator. NOTE: This configuration is not available forusers who weigh between 251-310lbs.

I10488 Corpus Seat w/ 45° Power Tilt & 175° Power Recline 10,995.00 E1007Includes a side mounted power recline actuator. This configuration cannot be selected with seatseat depths less than 18", and is not available for users who weigh between 251-310lbs.



Select Options:

I10495 Heavy Duty Package, R-net C400/C500 Corpus 2,545.00This item MUST be selected for any user between 251-310lbs. Available with the following seatingsystems: I10480 & I10486. Includes: Anti-tippers, Heavy Duty Arm Supports, & Heavy Duty Mountfor Recline. NOTE: For users between 266-310lbs: (1) The 45° Power Tilt Kit will be limited to aMAXIMUM of 30° of posterior tilt, (2) The overall back angle CANNOT exceed 150° in any seatpostion, and (3) driving will be inhibited if the seat elevator is raised.

I10013 Mount Seat Frame in Tall Position 317.00I10418 Single Seat Function Control Switch for R-net No Charge

Please choose either Push Buttons or Toggle Switches below.I10419 Single Seat Function Control Kit for R-net 1,478.00 E2310

For operation of a single seat function through the wheelchair electronics via the drive controland/or ICS Switchbox. Order with R-net Controller or remote joystick options. Please indicatebelow if you want push buttons or toggles on the Seat Function Control Kit.









Page 5 of 12Rev 2009-4 8/24/2009 3:10:34PM



Select Options:


Backrest Options


Required Items












Select Options:



Page 6 of 12Rev 2009-4 8/24/2009 3:10:34PM



Select Options:






Seat Sizing


Required Items




Select Options:



Armrest Options


Required Items

I103339-99-0 4"x10" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103341-99-0 4"x12" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103343-99-0 4"x14" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103345-99-0 4"x16" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103331-99-0 4"x10" Corpus Arm Right - Dual Taper, Black Fabric No Charge

Page 7 of 12Rev 2009-4 8/24/2009 3:10:34PM



Required Items

I103333-99-0 4"x12" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103335-99-0 4"x14" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI103337-99-0 4"x16" Corpus Arm Right - Dual Taper, Black Fabric No Charge


Required Items



Select Options:
















Legrest Options

Page 8 of 12Rev 2009-4 8/24/2009 3:10:34PM



Required Items




Select Options:







Accessories


Select Options:












Page 9 of 12Rev 2009-4 8/24/2009 3:10:34PM



Select Options:
























Page 10 of 12Rev 2009-4 8/24/2009 3:10:34PM




Required Items

















Select Options:


Page 11 of 12Rev 2009-4 8/24/2009 3:10:34PM




Required Items



Required Items



Required Items






Select Options:







Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 3:10:34PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:




Select Options:

I104020-99-0 C500 Lowrider R-net, 5.0mph - C500 PS2 11,535.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, 17" Seat to FloorHeight, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic TiresBelow.

I103968-99-0 C500 HS Lowrider R-net, 6.5mph - C500 PS2 12,685.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, R-net ESP (Enhanced Steering Performance), High Speed Motors,120 AMP Electronics, Tie-Down Hardware for Strap Systems, Charger, 17" Seat to Floor Height,Flat Free Tires, and Standard Positioning Belt. Must choose either Flat Free or Pneumatic Tires.


Required Items



Required Items



Required Items



Base Options


Required Items

I102273-99-0 Seat Tube Fixed No ChargeI103972-99-0 Power Adjustable Seat Height 6" Travel 2,995.00 E2300



Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I102210-99-0 Anti-Tippers for C400/C500 399.00I103635-99-0 Light Kit, R-net, C400/C500 955.00ID51113 Programming Key for R-net - Permobil Version 435.00

Permolock


Select Options:

Page 2 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:



Joystick Options


Required Items



Select Options:









Page 3 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:







Seating System


Required Items


I10489 Lowrider Seat w/20° Power Tilt & Manual Recline 6,995.00 E1002Includes a manual recline actuator mounted behind the backrest.

I10490 Lowrider Seat w/20° Power Tilt & 120° Power Recline 10,995.00 E1007Includes a powered recline actuator mounted behind the backrest.



Select Options:

I10496 Heavy Duty Package Lowrider w/ R-net 2,545.00Includes: Anti-tippers, heavy duty armrest supports, drive inhibit for power adjustable seat heightand heavy duty mount for recline. This is a required option for users between 251-310lbs.





Page 4 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:








Backrest Options


Required Items






Page 5 of 12Rev 2009-4 8/24/2009 3:11:11PM



Required Items





Select Options:








Seat Sizing


Required Items




Select Options:

Page 6 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:



Armrest Options


Required Items



Required Items



Select Options:









I100671-99-0 Armrest Pouch-Right 190.00I100672-99-0 Armrest Pouch-Left 190.00

Page 7 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:

I101261-99-0 Armrest Side Support Right Outer 142.00For Corpus Armrest Pads only.

I101262-99-0 Armrest Side Support Left Outer 142.00For Corpus Armrest Pads only.

I101263-99-0 Armrest Side Support Right Inner 142.00Recommend 2" wider width between the armrest to ensure armrests will flip-up.

I101264-99-0 Armrest Side Support Left Inner 142.00Recommend 2" wider width between the armrest to ensure armrests will flip-up.

I101510-99-0 Armrest Supports HD 486.00Cannot be ordered with 175 degree power recline seating systems. (I10482, I10485, I10488).

Legrest Options


Required Items


Includes calf supports.


Select Options:




I101276-99-0 Legrest Assm. 2pc Footplates (Complete) No ChargeI101277-99-0 Legrest Assm. 1pc Footplate 395.00I10006 3" Width Between Two- Piece Footplates 495.00


Accessories


Select Options:






Page 8 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:

























Page 9 of 12Rev 2009-4 8/24/2009 3:11:11PM



Select Options:







Required Items














Requires Omni Control Module. Cannot use this part with an Input Module.

Page 10 of 12Rev 2009-4 8/24/2009 3:11:11PM



Required Items

I10574 Sip & Puff System with Fiber Optic Opti-Stop 1,929.00 E2325,E2326Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tubekit.


Select Options:




Required Items



Required Items



Required Items






Select Options:


Page 11 of 12Rev 2009-4 8/24/2009 3:11:11PM






Signed:

Printed Name:

Title:

Date:


Page 12 of 12Rev 2009-4 8/24/2009 3:11:11PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC500 VS



Select Options:

I103265-99-0 C500 Base VS R-net, 5.0 mph - C500 PS2 11,785.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions , ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.

I104060-99-0 C500 Base VS, High Speed R-net, 6.5mph - C500 PS2 12,995.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions, Anti-Tippers,Shock Absorbing Suspension System, R-net ESP (Enhanced Steering Performance), High SpeedMotors, 120 AMP Electronics, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires.


Required Items



Required Items



Required Items



Base Options


Required Items

I103255-99-0 Power Adjustable Seat Height - 10" Travel 2,795.00 E2300This item must be selected. The lowest seat to floor height may be 18.5", 19.5" or 20.5"; however,this is a setting that must be adjusted prior to chair shipping from Permobil. Please indicate belowwhat seat to floor height you would like.


Required Items

I10504 Set Seat Height at 18.5" No ChargeI10505 Set Seat Height at 19.5" No ChargeI10506 Set Seat Height at 20.5" No Charge


Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I103635-99-0 Light Kit, R-net, C400/C500 955.00I309297-28-0 Anti-Tippers for C400 VS Jr & C500 VS 399.00

Anti-Tippers are required for any user weight above 220lbs. They are included in the High SpeedPackage for the C500 VS Base (I104060-99-0).

Page 2 of 11Rev 2009-4 8/24/2009 3:11:59PM



Select Options:



Permolock


Select Options:



I103242-99-0 3.6m Plunger Sw Ext Cable for VS with Permolock C No ChargeThis Cable MUST be selected when a Permolock C is ordered with a VS seating system.

Joystick Options


Required Items



Select Options:




Page 3 of 11Rev 2009-4 8/24/2009 3:11:59PM



Select Options:









I104002-99-0 Co-Pilot Attendant Control, VS R-net 4,175.00 E2331Custom charge may apply if ordering a backrest height of 21" or Lower.



Seating System


Required Items

VS Seat Note:You must select both part numbers listed below. The combined price includes: Seat Frame withAdjustable Depth, Fixed Chest Bar, Solid Seat Pan, Solid Backrest, and Height AdjustableArmrests. The weight capacity of the VS Seat is 265lbs; however, for clients who's weight isbetween 221-265lbs, the Power Recline Back Angle will be limited to 140°.

I10501 Power Tilt & Power Recline - VS Seat 10,695.00 E1007This item must be selected. Includes 25° Power Tilt & 175° Power Recline. If client weight isbetween 221-265lbs, the Power Recline angle will be limited to 140° when the chair is in a seatedposition. When in a standing position, the back angle will be able to open to 175°, regardless of theweight of the user.

I104134-99-0 Power Standing Function - VS Seat 5,495.00 E2301This item must be selected. Tilt Table Stand is not available for clients between 221-265lbs.



Required Items

Page 4 of 11Rev 2009-4 8/24/2009 3:11:59PM



Required Items



Select Options:





I103470-99-0 Mount ICS Switchbox on Backrest 125.00I104746-99-0 Remote Stop System - R-net, Pilot+ 985.00

Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on thewheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be usedtogether. Custom charge may be required if ordering with a low backrest height or a pediatricwheelchair. If ordering Remote Stop System with a K450, push handles must also be selected.

Backrest Options


Required Items


I100794-99-0 Ergo Back 14"W x 26.5"T - Leatherette, For Stander 837.00 E2620I100795-99-0 Ergo Back 16"W x 26.5"T - Leatherette, For Stander 837.00 E2620I100796-99-0 Ergo Back 18"W x 26.5"T - Leatherette, For Stander 837.00 E2620I10464 Ergo Back 14"W x 26.5"T - Black Mesh, For Stander 847.00 E2620I10465 Ergo Back 16"W x 26.5"T - Black Mesh, For Stander 847.00 E2620I10466 Ergo Back 18"W x 26.5"T - Black Mesh, For Stander 847.00 E2620I100434-99-0 Omit Backrest Kit 14" W Between Armrests No ChargeI100435-99-0 Omit Backrest Kit 16" W Between Armrests No ChargeI100436-99-0 Omit Backrest Kit 18" W Between Armrests No ChargeI10242 Solid Back for Standing Seat 16"W x 26.5"H No Charge

Standard Option with Tilt and/or Recline Systems. Includes Leatherette Back Cushion ONLY.I10243 Solid Back for Standing Seat - 18"W x 26.5"H No Charge

Standard Option with Tilt and/or Recline Systems. Includes Leatherette back cushion ONLY.


Select Options:

I10047 21" Back Height (Ergo Only) No ChargeI10014 Custom Backrest Height ______" 625.00

Backrest height measured from seat pan and cannot be lower than 19". Price in addition to abovebackrest.

Page 5 of 11Rev 2009-4 8/24/2009 3:11:59PM



Select Options:




I101101-99-0 Backrest Reinforcement 260.00I1824006 Sliding Backrest Kit for VS & VS Jr Seats 1,270.00

Provides 4" of mechanical shear reduction. Custom charge may be applied if ordering this item withany backrest shorter than 26.5".

Seat Sizing


Required Items

I103280-99-0 VS Seat Size 17"W x 16"D No ChargeI103281-99-0 VS Seat Size 17"W x 17"D No ChargeI103282-99-0 VS Seat Size 17"W x 18"D No ChargeI103283-99-0 VS Seat Size 17"W x 19"D No ChargeI103284-99-0 VS Seat Size 17"W x 20"D No ChargeI103285-99-0 VS Seat Size 17"W x 21"D No ChargeI103286-99-0 VS Seat Size 17"W x 22"D No ChargeI103287-99-0 VS Seat Size 19"W x 18"D No ChargeI103288-99-0 VS Seat Size 19"W x 19"D No ChargeI103289-99-0 VS Seat Size 19"W x 20"D No ChargeI103290-99-0 VS Seat Size 19"W x 21"D No ChargeI103291-99-0 VS Seat Size 19"W x 22"D No Charge


Select Options:



Armrest Options


Required Items



Required Items

Page 6 of 11Rev 2009-4 8/24/2009 3:11:59PM



Required Items



Required Items




Select Options:


I304969-99-0 18" Between Armrests w/ 16" Backrest 265.00I100523-99-0 Armrest Height Ext (+2") 125.00IARMADAP1" Arm Trough Adaptor 1" Pair 274.00









Legrest Options


Required Items

I10502 Power Articulating Center Mount Elevating Legrests 2,749.00 K0108This item must be selected.


Required Items

I103348-99-0 Stand & Drive Legrest Assembly - VS Seat 685.00 This item must be selected.

Page 7 of 11Rev 2009-4 8/24/2009 3:11:59PM



Required Items

I103353-99-0 Kneeblock Upholstery - Leatherette No ChargeI103352-99-0 Kneeblock Upholstery - Black Mesh 147.00


Select Options:

I103394-99-0 UT Calf Support Kit (J) w Mesh Cover & Adj Hdw - VS No ChargeI100979-99-0 Footplate, Fold / Lock Adult Legrest Only 363.00

Custom work will be necessary if ordering a 14" or lower leg length.

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10405 Bodypoint Padded Hip Belt UniTrack (N/C) - Medium No ChargeI10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955






4.5"W x 3.5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.I103079-99-0 UT Hip Suppt (A) w/ Mesh Cover - Low (Pair) 225.00 E0956

6"W x 5"T Pad w/ 2" Tall Mounting Bracket. Must also select PN I10550.I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) 225.00 E0956

6.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I103095-99-0 UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) 225.00 E0956

8"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I102977-99-0 UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) 225.00 E0956

12"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I305266-28-90-0 Lateral Supports Std. Leatherette-ErgoBack Only 246.00 E0956


Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I101099-99-0 Chest Bar 14" Adjustable Leatherette 245.00I307649-99-60-0 Chest Bar 14" Adjustable Black Mesh 265.00I101095-99-0 Chest Bar 16" Adjustable Leatherette 245.00I306688-99-60-0 Chest Bar 16" Adjustable, Black Mesh 265.00I101097-99-0 Chest Bar 18" Adjustable Leatherette 245.00I307650-99-60-0 Chest Bar 18" Adjustable Black Mesh 265.00I100978-99-0 Abductor Kit - Leatherette 306.00 E0957


Page 8 of 11Rev 2009-4 8/24/2009 3:11:59PM



Select Options:

I10555 Adj Removable - Abductor Hardware (1 Each) 212.00 E1028I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I101100-99-0 Push Handles for Standing Seat 339.00I101473-99-0 Back Pack Clips Carabiner Style 75.00I102059-99-0 Medical Necessities Bag 265.00








Must also select PN I10556.I10556 Adj Removable - Tray Hardware (1 Each) 212.00 E1028



Required Items











Page 9 of 11Rev 2009-4 8/24/2009 3:11:59PM



Required Items







Select Options:




Required Items



Required Items



Required Items






Select Options:

IMICROSWITCH Microlite Switch 148.00IBUDDYBUTTON Buddy Button 111.00 K0108

Page 10 of 11Rev 2009-4 8/24/2009 3:11:59PM



Select Options:

I5808 Mini Cup Switch 108.00IZTS-P Proximity Switch 515.00IMINIJOY5SW Mini Joystick 5 Switch OC 593.00I5018 Wafer Board w/5 Switches 497.00






Signed:

Printed Name:

Title:

Date:


Page 11 of 11Rev 2009-4 8/24/2009 3:11:59PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListC500 RS



Select Options:

I102891-99-0 C500 Base RS - C500 PS2 12,995.00 K0884Price Includes: FWD C500 Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires,Anti-Tippers, and a Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below.


Required Items



Required Items



Required Items



Base Options


Required Items

I10294 Power Adjustable Seat Height - 10" Travel 2,795.00 E2300To assist in transfers and improve access for function.


Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I103635-99-0 Light Kit, R-net, C400/C500 955.00ID51113 Programming Key for R-net - Permobil Version 435.00

Permolock


Select Options:


Page 2 of 10Rev 2009-4 8/24/2009 3:12:26PM



Select Options:


Joystick Options


Required Items



Select Options:

I102888-99-0 Mount R-net Joystick Panel on Right No ChargeI102889-99-0 Mount R-net Joystick Panel on Left No ChargeI103544-99-0 R-net Remote Joystick 530.00











Page 3 of 10Rev 2009-4 8/24/2009 3:12:26PM



Select Options:


Seating System


Required Items

I10293 ErgoCentric 75° Pwr Tilt & 150° Pwr Recline 12,464.00 E1007Price Includes: 75° Full Range of Motion Tilt (60° Posterior Tilt, 15° Anterior Tilt), 150° Dual ActionPower Recline with Shear Reduction, Seat Stabilizer, All Available Seat Sizes. Weight Limit 300lbs.



Required Items

I102995-99-0 Multiple Seat Function Control Kit for RNet 2,995.00 E2311For operation of two or more seat functions through the wheelchair electronics. This also includesthe Intelligent Control System (ICS). The ICS allows the user to program up to three memorypositions for the seating system. The Multiple Seat Function Control Kit also includes the ICSSwitchbox, which provides another means of controlling the seat functions.


Required Items



Select Options:

I1822846 Mount ICS Switchbox onto End of Armrest Pad No ChargeICS Switchbox will be mounted to the end of the armrest pad. If this item is selected, the ICSSwitchbox will NOT swing away with the Joystick Module. Please indicate below if you would like itmounted onto the left or right arm pad.






Backrest Options

Page 4 of 10Rev 2009-4 8/24/2009 3:12:26PM



Required Items

REQUIRED - LOWER BACKREST WIDTHPrice Includes: The Lower Backrest, Element 1, and all width adjustments. All backrests andelements include cushions with mesh covers. The RS Backrest comes standard with the capabilityto split the lower backrest from the attached elements.

I102952-99-0 Lower Back: 14"-18" Wide - Infinite Adjustment 795.00I102955-99-0 Lower Back: 18"-22" Wide - Infinite Adjustment 795.00


Required Items

REQUIRED - ELEMENT 1 (BACK HEIGHT = 18.5")I102953-99-0 Element 1: 14" Wide - No Width Adjustment No ChargeI102954-99-0 Element 1: 14"-17" Wide - Infinite Adjustment No ChargeI102956-99-0 Element 1: 17"-20" Wide - Infinite Adjustment No ChargeI102957-99-0 Element 1: 20"-22" Wide - Infinite Adjustment No Charge


Select Options:

OPTIONAL - ELEMENT 2 (BACK HEIGHT = 22.5")I102986-99-0 Element 2: 14" Wide - No Width Adjustment 275.00I102987-99-0 Element 2: 14"-17" Wide - Infinite Adjustment 275.00I102988-99-0 Element 2: 17"-20" Wide - Infinite Adjustment 275.00I102962-99-0 Element 2: 20"-22" Wide - Infinite Adjustment 275.00

OPTIONAL - ELEMENT 3 (BACK HEIGHT = 26.5")I102996-99-0 Element 3: 14" Wide - No Width Adjustment 275.00I102997-99-0 Element 3: 14"-17" Wide - Infinite Adjustment 275.00I102998-99-0 Element 3: 17"-20" Wide - Infinite Adjustment 275.00I102999-99-0 Element 3: 20"-22" Wide - Infinite Adjustment 275.00

-------------------------------------------------- --------------------------------------------------I102971-99-0 Anterior Flexion for Element 1 No Charge

Allows for anterior flexion of all Elements added to the lower backrest. Elements 2 and 3 comestandard with adjustable anterior flexion. The Lower Backrest will never have anterior flexion.Cannot be ordered with Backrest Rotation (I102967-99-0).

I102967-99-0 Upper Torso Rotation for Backrest Elements 895.00Allows for rotation of all the Elements added to the Lower Backrest. The Lower Backrest will notrotate. The tension of the backrest rotation is adjustable, and can tightened to the point where it isalmost completely rigid. If Elements 2 or 3 are ordered when this option is selected, it will bepossible to adjust the anterior flexion of Elements 2 or 3 as well. Cannot be ordered with AnteriorFlexion for Element 1 (I102971-99-0).

Seat Sizing


Required Items

I102904-99-0 RS Seat w/ Ergonomic Mesh Cushion 16" W x 16" D 485.00I102908-99-0 RS Seat w/ Ergonomic Mesh Cushion 16" W x 18" D 485.00I102912-99-0 RS Seat w/ Ergonomic Mesh Cushion 16" W x 20" D 485.00I102916-99-0 RS Seat w/ Ergonomic Mesh Cushion 16" W x 22" D 485.00I102905-99-0 RS Seat w/ Ergonomic Mesh Cushion 18" W x 16" D 485.00I102909-99-0 RS Seat w/ Ergonomic Mesh Cushion 18" W x 18" D 485.00I102913-99-0 RS Seat w/ Ergonomic Mesh Cushion 18" W x 20" D 485.00I102917-99-0 RS Seat w/ Ergonomic Mesh Cushion 18" W x 22" D 485.00I102906-99-0 RS Seat w/ Ergonomic Mesh Cushion 20" W x 16" D 485.00I102910-99-0 RS Seat w/ Ergonomic Mesh Cushion 20" W x 18" D 485.00

Page 5 of 10Rev 2009-4 8/24/2009 3:12:26PM



Required Items

I102914-99-0 RS Seat w/ Ergonomic Mesh Cushion 20" W x 20" D 485.00I102918-99-0 RS Seat w/ Ergonomic Mesh Cushion 20" W x 22" D 485.00I102907-99-0 RS Seat w/ Ergonomic Mesh Cushion 22" W x 16" D 485.00I102911-99-0 RS Seat w/ Ergonomic Mesh Cushion 22" W x 18" D 485.00I102915-99-0 RS Seat w/ Ergonomic Mesh Cushion 22" W x 20" D 485.00I102919-99-0 RS Seat w/ Ergonomic Mesh Cushion 22" W x 22" D 485.00I102936-99-0 RS Seat - 16" W x 16" D No ChargeI102940-99-0 RS Seat - 16" W x 18" D No ChargeI102944-99-0 RS Seat - 16" W x 20" D No ChargeI102948-99-0 RS Seat - 16" W x 22" D No ChargeI102937-99-0 RS Seat - 18" W x 16" D No ChargeI102941-99-0 RS Seat - 18" W x 18" D No ChargeI102945-99-0 RS Seat - 18" W x 20" D No ChargeI102949-99-0 RS Seat - 18" W x 22" D No ChargeI102938-99-0 RS Seat - 20" W x 16" D No ChargeI102942-99-0 RS Seat - 20" W x 18" D No ChargeI102946-99-0 RS Seat - 20" W x 20" D No ChargeI102950-99-0 RS Seat - 20" W x 22" D No ChargeI102939-99-0 RS Seat - 22" W x 16" D No ChargeI102943-99-0 RS Seat - 22" W x 18" D No ChargeI102947-99-0 RS Seat - 22" W x 20" D No ChargeI102951-99-0 RS Seat - 22" W x 22" D No Charge

Armrest Options


Required Items

I10296 Multi-Axis Arm Support 284.00 E0973The armrest assembly is height, width, length, and angle adjustable. Armrest pad is 4" x 16".Usable armrest length can be infinitely adjustable from 12" - 16". Price also includes the ability torotate the front of the armrest pad inward toward the user to create more of a midline mount.

Legrest Options


Required Items

I10295 Power Articulating Center Mount Elevating Legrest 2,749.00 K0108


Required Items

I100561-99-0 Legrest Assm. 1pc Footplate (Complete) 395.00I101276-99-0 Legrest Assm. 2pc Footplates (Complete) No Charge


Select Options:




Page 6 of 10Rev 2009-4 8/24/2009 3:12:26PM



Select Options:



Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10405 Bodypoint Padded Hip Belt UniTrack (N/C) - Medium No ChargeI10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I102822-99-0 Positioning Belt Retractable - RS 225.00 K0108I102823-99-0 Positioning Belt Retractable Long - RS 245.00 K0108I102974-99-0 RS Headrest, Black Fabric 375.00

Must also select I10552.I1823249 UT Lateral Adjustment Bar for UniTrack Headrest 55.00

Allows for approximately 4" of lateral adjustment to the UT Ergo Headrest either right or left. NOTE:Due to the width of this item (approx 9"), it may be necessary to send other items such as backpack clips unmounted. Custom charge may apply with lower back heights.










I10550 Adj Removable - Thigh Support Hardware (Pair) 424.00 E1028I103648-99-0 Lateral Support (F) - RS w/ Mesh Cover - Medium 285.00

8.5"D x 3.5"T Pad. Must also select PN I10551.I103650-99-0 Lateral Support (E) - RS w/ Mesh Cover - Large 285.00

8.5"D x 6"T Pad. Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I103044-99-0 Cup Holder for RS Seat 45.00I101500-99-0 Essentials Carrier for Chassis 379.00I103426-99-0 Upper Extremity Support Angle Adjust - UniTrack 296.00 E0950



Page 7 of 10Rev 2009-4 8/24/2009 3:12:26PM



Select Options:

I103652-99-0 Push Handles for RS Seat 365.00



Required Items

















Select Options:

I10076 Right Side Mount For Joystick No ChargeI10077 Left Side Mount For Joystick No ChargeI10074 Right Side Mount For Omni No ChargeI10075 Left Side Mount For Omni No ChargeI10078 Mount Seat Control Panel on Right No Charge

Page 8 of 10Rev 2009-4 8/24/2009 3:12:26PM



Select Options:

I10079 Mount Seat Control Panel on Left No ChargeI10080 Mount Seat Control Panel on Backrest No Charge



Required Items



Required Items



Required Items






Select Options:


Page 9 of 10Rev 2009-4 8/24/2009 3:12:26PM






Signed:

Printed Name:

Title:

Date:


Page 10 of 10Rev 2009-4 8/24/2009 3:12:26PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListStreet Corpus



Select Options:

I103261-99-0 Street Base Corpus R-net 10,565.00 K0884Price Includes: RWD Street Power Base Set Up For Multiple Power Seat Functions, Four-WheelAdjustable Independent Suspension System, High Speed Four Pole Motors and Custom GearBoxes Designed for Maximum Reliability and Performance, 120 AMP R-net Electronics, Tie- DownHardware for Strap Systems, Charger, and Standard Positioning Belt. Must Choose Flat Free orPneumatic Tires Below.


Required Items

I104403-99-0 Tri Spoke Split Rim w/ FF Drive Tires - 3.5 x 8" No ChargeI104402-99-0 Tri Spoke Split Rim w/ Pneumatic - 3.5 x 8" No Charge


Required Items

I102012-99-0 Street Base Cover Gold/Black No ChargeI102010-99-0 Street Base Cover Blue/Green Iridescent No ChargeI102009-99-0 Street Base Cover Copper Metallic No Charge

Base Options


Required Items

I104387-99-0 Power Adjustable Seat Height, 10" Travel R-net 2,795.00 E2300To assist in transfers and improve access for function. Note: With power seat elevator, chair will gointo 1/2 Speed at 1.5" of Elevation, and into 1/4 Speed at 2.5" of Elevation.

I102046-99-0 Fixed Seat Height No Charge


Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I104384-99-0 Street Light Kit - R-net 1,010.00ID51113 Programming Key for R-net - Permobil Version 435.00

Joystick Options


Required Items



Select Options:

I10412 Joystick Mount Right - Fixed, R-net Only No Charge

Page 2 of 11Rev 2009-4 8/24/2009 3:13:50PM



Select Options:

I10413 Joystick Mount Left - Fixed, R-net Only No ChargeI102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 292.00 E1028I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 292.00 E1028I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 Only 486.00 E1028I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 Only 486.00 E1028I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028














Seating System


Required Items


Page 3 of 11Rev 2009-4 8/24/2009 3:13:49PM



Required Items

I10125 Corpus Seat HD without Pwr Tilt or Pwr Recline 5,595.00 K0108Weight Limit 310 lbs.

I10516 Corpus Seat w/ 45° Power Tilt & Manual Recline 6,726.00 E1002Note: Chair will go into 1/4 Speed at 20° of Tilt, then drive will be inhibited at 30° of Tilt.

I10517 Corpus Seat w/ 135° Power Recline 7,415.00 E1004Includes a side mounted power recline actuator. Note: Chair will go into 1/4 Speed at 125° ofBackrest Angle.

I10518 Corpus Seat w/ 45° Power Tilt & 135° Power Recline 10,995.00 E1007Includes a side mounted power recline actuator. Note: Chair will go into 1/4 Speed at 20° of Tilt,then drive will be inhibited at 30° of Tilt. Chair will go into 1/4 speed at 125° of Backrest Angle.



Select Options:











Backrest Options


Required Items


Page 4 of 11Rev 2009-4 8/24/2009 3:13:50PM



Required Items









Select Options:








Seat Sizing


Required Items

Page 5 of 11Rev 2009-4 8/24/2009 3:13:50PM



Required Items




Select Options:



Armrest Options


Required Items



Required Items



Select Options:

I10137 Height Adjustable Armrest Assembly 284.00 E0973

Page 6 of 11Rev 2009-4 8/24/2009 3:13:50PM



Select Options:















Legrest Options


Required Items

I104385-99-0 Power Articulating Center Mount Elevating Legrest 2,749.00 K0108Driving speed will be reduced when the legrest is pulled in towards the casters. The angle at whichthe speed is reduced will vary depending on the seat depth of the wheelchair. The speed isreduced to prevent the casters from striking the footplates at high speeds.

I102212-99-0 Manual Adjustment Legrest Elevation No ChargeIncludes Calf Supports.


Select Options:




I102051-99-0 Legrest Assm. 2pc Narrow Footplates (Complete) No Charge

Page 7 of 11Rev 2009-4 8/24/2009 3:13:50PM



Select Options:


Accessories


Select Options:


















Must also select PN I10555.I10555 Adj Removable - Abductor Hardware (1 Each) 212.00 E1028I10015 Knee Block Assembly Corpus 630.00 K0108I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00

Page 8 of 11Rev 2009-4 8/24/2009 3:13:50PM



Select Options:

I100975-99-0 Push Handles for Ergo Backrest 339.00Order with Ergonomic or Rectangular Backs. Custom charge may apply if ordering push handleswith an articulating vent tray.


















Required Items




For neck width up to 5".

Page 9 of 11Rev 2009-4 8/24/2009 3:13:50PM



Required Items

I10562 Gimble Joystick w/ Haims Harness - Large 1,555.00 E2373For neck width up to 7".

I10563 Gimble Joystick w/ Power Swing Away Chin Boom 5,174.00 E2399Custom charge may be applied if ordering smaller backrest sizes and heights.

I10564 Mini Joystick set up for Armrest Mount 2,035.00 E2312I10565 Mini Joystick set up for Midline Mount 2,035.00 E2312I10566 Mini Joystick set up for Swing Away Chin Boom 2,035.00 E2312











Select Options:




Required Items



Required Items



Required Items


Page 10 of 11Rev 2009-4 8/24/2009 3:13:50PM



Required Items





Select Options:







Signed:

Printed Name:

Title:

Date:


Page 11 of 11Rev 2009-4 8/24/2009 3:13:50PM

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListChairman HD3



Select Options:

I101233-99-0 Chairman HD3 Base W/ Lights 11,595.00Price includes: FWD Power Base Set Up for Multiple Power Options, Tie Down Hardware for StrapSystems. Lights, Seat Stabilizers, HD Seat Post, Anti-tippers, Dual Rear Casters, Long PositioningBelt, and Charger.


Required Items

I310158-FF Flat Free Drive Tires for HD3 or Robo No ChargeI310158-99-0 Pneumatic Drive Tires for HD3 or Robo No Charge

Base Options


Required Items

I100500-99-0 Power Adjustable Seat Height, HD3 8" Travel 2,895.00 E2300To assist in transfers. Drive inhibited when raised.

I100702-99-0 Seat Tube Fixed HD3 No Charge


Select Options:

IM24 SLD G FT Batteries, Group 24 Sealed LA/Gel, Installed 762.00 E2363I602307-99-0 P+ PP1A Programmer - VSI, VR2 or Pilot+ Controllers 595.00

Joystick Options


Required Items



Select Options:

I10127 Fixed Joystick Mount - Right No ChargeI10136 Fixed Joystick Mount - Left No ChargeI101243-99-0 Joystick Mount Right - Swing Away 292.00 E1028I101242-99-0 Joystick Mount Left - Swing Away 292.00 E1028I100819-99-0 Retractable Joystick Mnt Right 486.00 E1028I100824-99-0 Retractable Joystick Mnt Left 486.00 E1028I101260-99-0 Midline Control Mount - Pilot+ & R-net Only 263.00 E1028

Please indicate which armrest to mount midline below.I10428 Mount Midline Joystick on Left Armrest No ChargeI10427 Mount Midline Joystick on Right Armrest No Charge

Page 2 of 8Rev 2009-4 8/24/2009 3:12:54PM



Select Options:

ID49670/3 Pilot+ series Joystick w/ 7 Buttons - No Charge No ChargeComes standard when ordering zero or one power option.

I10207 Pilot+ Series Joystick w/ 7 Buttons 530.00Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. MUST order expandable controller (PN: I10450) with this part.

ID49880 Pilot+ Joystick M/J 530.00Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. MUST order expandable controller (PN: I10450) with this part.1/8" mini-mono jacks for power and mode.

ID50002 Pilot+Series Joystick T/S 530.00Expandable/remote joystick used with multiple power option bases or as an upgrade for no poweroption or single power option bases. MUST order expandable controller (PN: I10450) with this part.Toggle switches for power and mode.

I10450 Expandable Controller - Pilot Plus 525.00 E2377MUST be ordered with the expandable/remote joysticks (PN: I10207, ID49880, or ID50002).


ID49682 P+DAC Attendant Control - Pilot+ Controller Only 1,136.00 E2331Not available with VR2 controllers. Will be sent as part if ordering sling back upholstery.

I103181-99-0 Co-Pilot Attendant Control - Corpus 2,626.00 E2331Custom charge may apply if ordering a Corpus Tubular Backrest OR a backrest height of 21" orLower. Not available with VR2 Controllers.

Seating System


Required Items

The Seating System Listed Below Includes:HD3 Corpus Seat Frame, Back Frame with Power Recline, Reclining Armrest Assembly, Solid SeatPan (19"w x 19"d), Legrest Assembly with Adjustable Elevation. Weight Limit 440lbs.

I100501-99-0 HD3 Seat w/ NO Tilt & 120° Power Recline 8,834.00 K0108I100473-99-0 HD3 Seat w/ 30° Power Tilt & 120° Power Recline 11,395.00 E1007

Drive inhibited when tilted past 7 degrees.



Select Options:

I10128 Single Seat Function Control Switch No ChargeI102057-99-0 Multiple Seat Function Control Kit 2,875.00 E2311

MUST be selected if ordering two or more seat functions. This device is used to operate two ormore seat functions through the wheelchair electronics via the drive controls and/or membraneswitch box. Order with Pilot+ or remote joystick options. Not available with VSI Controllers.

I10129 Single Seat Function Control Kit 1,478.00 E2310For operation of a single seat function through the wheelchair electronics via the drive controlsand/or membrane switch box. Order with Pilot+ or remote joystick options. Not available with VSIControllers.


ISW-JOY Seat Control Joyswitch 1,451.00 K0108Multi directional toggle to operate up to 4 power seat functions. Provides an additional method toaccessing the seat functions. You must still order the Multiple Seat Function Control Kit if selectingthis part. Please specify where to mount membrane switchbox: Right Arm Pad: _____ LeftArmrest Pad:_____

Page 3 of 8Rev 2009-4 8/24/2009 3:12:54PM



Select Options:

I10253 Mount Joyswitch on Left No ChargeI10254 Mount Joyswitch on Right No ChargeISW-ALT Altswitch Alternating Seat Control 985.00 K0108

Seat function interface box which accommodates 4 single momentary switches. 1/8" mini-monoswitches not included. Provides an additional method to accessing the seat functions. You muststill order the Multiple Seat Function Control Kit if selecting this part.


Backrest Options


Required Items



Select Options:

I10023 HD 3 Backrest Fixed, Rectangular - Leatherette No ChargeHD3 Backrest has a metal pan and is 28" High from the seat pan. The width is 1" narrower thanthe seat width.


Seat Sizing


Required Items

I101019-99-0 HD Seat 19"W x 15"D No ChargeI101020-99-0 HD Seat 19"W x 17"D No ChargeI101021-99-0 HD Seat 19"W x 19"D No ChargeI101022-99-0 HD Seat 19"W x 21"D No ChargeI101023-99-0 HD Seat 19"W x 23"D No ChargeI101024-99-0 HD Seat 21"W x 15"D No ChargeI101025-99-0 HD Seat 21"W x 17"D No ChargeI101026-99-0 HD Seat 21"W x 19"D No ChargeI101027-99-0 HD Seat 21"W x 21"D No ChargeI101028-99-0 HD Seat 21"W x 23"D No ChargeI101029-99-0 HD Seat 23"W x 15"D No ChargeI101030-99-0 HD Seat 23"W x 17"D No ChargeI101031-99-0 HD Seat 23"W x 19"D No ChargeI101032-99-0 HD Seat 23"W x 21"D No ChargeI101033-99-0 HD Seat 23"W x 23"D No Charge


Select Options:


Page 4 of 8Rev 2009-4 8/24/2009 3:12:54PM



Select Options:


Armrest Options


Required Items


No charge with power tilt and/or recline.


Select Options:

I103344-99-0 4"x16" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103345-99-0 4"x16" Corpus Arm Right - Dual Taper, Leatherette No ChargeI103336-99-0 4"x16" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103337-99-0 4"x16" Corpus Arm Right - Dual Taper, Black Fabric No ChargeI100523-99-0 Armrest Height Ext (+2") 125.00IARMADAP1" Arm Trough Adaptor 1" Pair 274.00









Legrest Options


Required Items

I100503-99-0 Power Articulating Center Mount Elevating Legrests 2,749.00 K0108Elevation limited to 65 degrees. Includes Calf Supports.

I100502-99-0 Manual Adjustment Legrest Elevation No ChargeIncludes Calf Supports.


Select Options:

I100515-99-0 Calf Supports Leatherette No ChargeNot available with lower leg lengths of 9" or less

I10462 UT Calf Support (H) w/ Mesh Cover & Adj Hardware No Charge7"W x 7"T Curved Pad. No Charge on HD3 ONLY.

I100475-99-0 Footplate assembly--1 pc 395.00I100474-99-0 Footplate assembly--2 pc No Charge

Page 5 of 8Rev 2009-4 8/24/2009 3:12:54PM


Accessories


Select Options:

I100600-99-0 Positioning Belt Retractable Long 255.00 K0108I100507-99-0 Positioning Belt Long No Charge

Included in Basic Equipment Package.I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955
















Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I100975-99-0 Push Handles for Ergo Backrest 339.00



Includes Back Pack Clips (Carabiner Style).I102697001331 Medical Necessities Bag - Case Logic 265.00I101964-99-0 Oxygen Holder for PS or Corpus Seat 224.00


Page 6 of 8Rev 2009-4 8/24/2009 3:12:54PM




Required Items

Pilot Plus Alternative Drive Input DevicesPilot + Alt Drive Input Devices take the place of, or may be used in addition to, the standard Pilot +Joystick. They are only usable on wheelchairs that have Pilot + electronics. You MUST select oneof each of the following items: (1) Input Device, (2) Expandable Controller, (3)Adjustable/Removable Alt Drive Hardware, AND (4) Omni Plus Control Module.
















Select Options:



Page 7 of 8Rev 2009-4 8/24/2009 3:12:54PM



Required Items



Required Items



Required Items

(4) OMNI PLUS CONTROL MODULE (REQUIRED)I10073 Omni Plus Control Module for Pilot Plus 1,470.00 E2399

Please specify input method if not ordering from Permobil. Input Device:________________________



Select Options:

IMICROSWITCH Microlite Switch 148.00IBUDDYBUTTON Buddy Button 111.00 K0108I5808 Mini Cup Switch 108.00IZTS-P Proximity Switch 515.00IMINIJOY5SW Mini Joystick 5 Switch OC 593.00I5018 Wafer Board w/5 Switches 497.00ID00005 Dual Control Switch Box 859.00ID49871 Auxiliary Control Module 877.00 E2351I10082 Chin Control Unit Stand Alone 1,215.00 E2373,E1028

Includes: P & G Chin Control Unit and swing away mount off the backrest. (Do not need Omni PlusControl Module).






Signed:

Printed Name:

Title:

Date:


Page 8 of 8Rev 2009-4 8/24/2009 3:12:54PM

PO#:

Dealer Name:

Address:

Phone#:

Contact:

Permobil Dealer Code:

City:

Fax#:

First Name:

Last Name:

State/Zip:

Serial Number of Wheelchair:

Permobil requires that a Permolock Base be installedby a NMEDA Dealer.

Dealer Information

Client Information

Permolock

NMEDA Certification #:

MSRP Price ListSelect Options:Part Number Description Price

I102843-99-0 Permolock Kit - COMPLETE 2,485.00Includes: Locking Base, Plunger, and Manual Release Handle. The Locking Base must beinstalled by a NMEDA Dealer. Please provide the NMEDA Dealer Name & Address wherethe locking Base will ship to. .NAME:_____________________________________________ .. . .ADDR:_____________________________________________

I102840-99-0 Base ONLY for Permolock 1,913.00Price Includes: Locking Base only. This item must be installed by a NMEDA Dealer.

I102842-99-0 Plunger ONLY for Permolock 1,008.00Price Includes: Plunger only. This item may be purchased by any Permobil Inc or NMEDAcertified dealer. The standard mounting position for the button to control the plunger is atthe end of the armrest pad, opposite the joystick.

I102841-99-0 Manual Release Handle ONLY for Permolock 259.00Price Includes: Manual Release Handle only. This item may be purchased by anyPermobil Inc or NMEDA Certified Dealer.

I1820550 Permolock OEM Seat Install Bracket 525.00Allows for installation of original automotive seat.

I1821551 Permolock Height Adapter for OEM Seat Bracket 515.00Used in combination with the OEM Seat Install Bracket to provide height adjustablity oforiginal automotive seat. Range of height adjustability is 8" - 12", in 1" increments.

Prices effective October 28, 2008. All specifications and prices are subject to change without notice. Pleasenote that prices displayed are only valid if the order is for a new Permolock. Any parts ordered for service orfuture alterations will carry different pricing and warranty.

Please send order/quote to fax#: (800) 231-3256Permobil Inc.

6961 Eastgate Blvd.Lebanon, TN 37090Tel: (800) 736-0925Fax: (800) 231-3256

Rev 2008-4 10/27/2008

Permobil Inc 6961 Eastgate Blvd. Lebanon, TN 37090 Phone: 800-736-0925, Fax: 800-231-3256Page 2 of 2

Rev 2008-2 2/13/08

The New Permolock Features:

Retractable Plunger – First on the market and provides better ground clearance. No moredamaged thresholds or carpets.

Ease of Installation - The C400 or C500 base is already set up to accept the Permolockplunger. The Permolock base mounts easily in vehicles.

Stability - When pulling a wheelchair into the Permolock base the drive wheel suspensionsare locked out providing a much more stable base to drive from.

Drive From Wheelchair - We endorse passengers riding in Permobil wheelchairs when usingthe Permolock (see memo below).

Memo on Transporting Wheelchairs in Vehicles Using Permolock

A user may ride in a Permobil C400 or C500 of appropriate configuration in a motor vehicle, whenproperly secured by both a Permolock wheelchair lockdown system AND a crash tested lap andshoulder belt, which is secured to the motor vehicle. A “crash tested lap belt” does NOT include thepositioning belt attached to the wheelchair. The wheelchair belt is designed to position the user in thewheelchair during ordinary use. It is not designed to protect the user against injury while riding in thewheelchair in a vehicle. Users who pursue riding in or driving vehicles in their wheelchairs assume agreat risk. We urge them to give careful consideration to this pursuit.

Table of Approved C400 and C500 Configurations that may be used with Permolock

Chassis Seating System Seating System OptionsCorpus II All Power FunctionsCorpus II with "Side Mounted" ReclineCorpus II with Center-Mounted ReclineCorpus II with Manual Recline (Side) and/or LegsCorpus II with Power Seat ElevatorCorpus II with Fixed Seat TubeCorpus II with 30° TiltCorpus II with 45° TiltLowrider All Power FunctionsLowrider with Manual Recline and/or LegsLowrider with Fixed Seat TubeStander All Configurations

C400

C500

RS All Configurations

Complete Kit Part #I102843-99-0 Includes:

PermolockBase#I102840-99-0

ManualReleaseLever#I102842-99-0

PermolockRetractablePlunger#I102841-99-0

PO#:

* Dealer Name:

Address:

* Phone#:

* Contact:

Dealer Code:

* City:

* Fax#:

* First Name:

* Last Name:

* Weight:

*Height:


B) Chest Depth:

C) Chest Width:

D) Seat Depth:

E) Top of Head:

F) Elbow to Hand:


H) Hip Width:





* State/Zip:

Diagnosis:


Dealer Information

Client Information

Client Measurements


Funding Source:


Client Age:

MSRP Price ListX850 Corpus



Select Options:

I103005-99-0 X850 Corpus 12,975.00 K0014Price Includes: 9 mph RWD Power Base, Servo Controlled Front Steering Mechanism, Lights,Four-Wheel Independent Suspension System, and Charger.


Required Items

I103173-99-0 X850 Shroud Vintage Wine No ChargeI103174-99-0 X850 Shroud Crystal Blue No ChargeI103175-99-0 X850 Shroud Metallic Charcoal Gray No Charge

Base Options


Required Items

I103022-99-0 Power Adjustable Seat Height, X850 - 8" Travel 2,795.00 E2300Half speed drive limitation when elevated.

I103033-99-0 Fixed Seat Height No ChargeDelivery time will be increased when ordering this item.


Required Items

I103012-99-0 Power Base Extender 2,895.00 This item must be selected. Enables the user to lengthen the wheel base up to 8" for increasedstability.


Select Options:

I101999-99-0 Batteries, Grp 31 (97AH) Sealed LA/Gel, Installed 985.00I103038-99-0 Luggage Box - Rear Mounted 875.00I100292-99-0 Crutch Holder X850 Right - Mounted to Base 375.00 K0102I100293-99-0 Crutch Holder X850 Left - Mounted to Base 375.00 K0102I103101-99-0 Side Rear Veiw Mirror Mounted on Right Front 415.00I103137-99-0 Side Rearview Mirror Mounted on Left Front 415.00I101892-99-0 Foot Rest Buildup Kit w/ 1 Piece Footplate - X850 625.00

This item mounts to the footrest wells on the front extension of the base. It reduces the distancebetween the seat pan and the footrest wells by up to 4".

Joystick Options


Required Items

I10045 Cone Shaped Joystick Knob - Standard. No ChargeI100960-99-0 Chin Cup For Joystick Knob 94.00 E2324I100961-99-0 "T" Handle For Joystick Knob 139.00 E2323I100962-99-0 "Large Ball" For Joystick Knob 94.00 E2323I100963-99-0 "Softball" For Joystick Knob 127.00 E2323I100964-99-0 "Mushroom" For Joystick Knob 127.00 E2323I100965-99-0 "Stick" For Joystick Knob 127.00 E2323


Required Items

Page 2 of 8Rev 2009-4 8/24/2009 3:16:25PM



Required Items

I103024-99-0 Safegate Remote Joystick Module 1,645.00 This item must be selected. Price includes all expandable electronics.


Select Options:

I100526-99-0 Joystick Mount-Right Swing Away 281.00 E1028I100525-99-0 Joystick Mount-Left Swing Away 281.00 E1028I100819-99-0 Retractable Joystick Mnt Right 486.00 E1028I100824-99-0 Retractable Joystick Mnt Left 486.00 E1028

Seating System


Required Items

The Seating Systems Listed Below Include:Corpus Seat Frame, Solid Backrest (Standard Size), Height Adjustable Armrest Assembly (NoCharge if ordering Power Tilt or Recline), All Seat Pan Sizes. Weight Limit 300lbs.

I10600 X850 Corpus Seat w/ Manual Recline & No Tilt 5,595.00Delivery time will be increased when ordering this item.

I10601 X850 Corpus Seat w/ 120° Power Recline & No Tilt 6,995.00 E1004Includes power recline actuator mounted behind the back with a reinforced mounting system.Delivery time will be increased when ordering this item.

I10602 X850 Corpus Seat w/ 16° Pwr Tilt & Manual Recline 6,340.00 E1002Cannot order any swivel seat (I103023-99-0 or I103009-99-0) with powered tilt.

I10603 X850 Corpus Seat w/ 16° Pwr Tilt & 120° Pwr Recl 10,995.00 E1007Includes power recline actuator mounted behind the back with a reinforced mounting system.Cannot order any swivel seat (I103023-99-0 or I103009-99-0) with powered tilt.


Required Items

I103013-99-0 No Swivel on Seat No ChargeThis item must be selected if ordering power tilt.

I103023-99-0 Manual Swivel Seat 2,455.00Swivel seat CANNOT be ordered with power tilt. Delivery time will be increased when ordering thisitem. Drive lockout when seat is swiveled.

I103009-99-0 Powered Swivel Seat 3,453.00Swivel seat CANNOT be ordered with power tilt. Delivery time will be increased when ordering thisitem. Drive lockout when seat is swiveled.



Select Options:

I100590-99-0 Multiple Seat Function Control Kit 2,875.00 E2311MUST be selected if ordering two or more seat functions. This device is used to operate two ormore seat functions through the wheelchair electronics via the membrane switchbox.

I10129 Single Seat Function Control Kit 1,478.00 E2310For operation of a single seat function through the wheelchair electronics via the drive controlsand/or membrane switch box. Order with Pilot+ or remote joystick options. Not available with VSIControllers.


Page 3 of 8Rev 2009-4 8/24/2009 3:16:25PM



Select Options:


Backrest Options


Required Items


I101853-99-0 Ergo Back Fixed 14" W x 21" H - Leatherette 837.00 E2620I101863-99-0 Ergo Back Fixed 14"W x 26.5" High - Leatherette 837.00 E2620I101854-99-0 Ergo Back Sliding 16"W x 21"H - Leatherette 837.00 E2620I101861-99-0 Ergo Back Sliding 16"W x 26.5" H - Leatherette 837.00 E2620I101855-99-0 Ergo Back Sliding 18"W x 21"H - Leatherette 837.00 E2620I101862-99-0 Ergo Back Sliding 18"W x 26.5"H - Leatherette 837.00 E2620I305510-00-90-0 Ergo Back Fixed Tall 16"W x 29.5"H - Leatherette 837.00 E2620I10455 Ergo Back Fixed 14" W x 21" H - Black Mesh 859.00 E2620I10456 Ergo Back Fixed 14"W x 26.5" High - Black Mesh 859.00 E2620I10457 Ergo Back Sliding 16"W x 21"H - Black Mesh 859.00 E2620I10458 Ergo Back Sliding 16"W x 26.5" H - Black Mesh 859.00 E2620I10459 Ergo Back Sliding 18"W x 21"H - Black Mesh 859.00 E2620I10460 Ergo Back Sliding 18"W x 26.5"H - Black Mesh 859.00 E2620I10005 Rectangular Back 18"W - Metal Fixed 1,307.00







Select Options:





Page 4 of 8Rev 2009-4 8/24/2009 3:16:25PM



Select Options:




Seat Sizing


Required Items


I100684-99-0 Corpus Seat 17"W x 16"D No ChargeI100689-99-0 Corpus Seat 17"W x 18"D No ChargeI100695-99-0 Corpus Seat 17"W x 20"D No ChargeI100720-99-0 Corpus Seat 17"W x 22"D No ChargeI100690-99-0 Corpus Seat 19"W x 18"D No ChargeI100696-99-0 Corpus Seat 19"W x 20"D No ChargeI100721-99-0 Corpus Seat 19"W x 22"D No ChargeI10007 Special Seat Size 21"W x 18"D No ChargeI10008 Special Seat Size 21"W x 20"D No ChargeI10009 Special Seat Size 21"W x 22"D No Charge


Select Options:



Armrest Options


Required Items



Required Items

I103338-99-0 4"x10" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103340-99-0 4"x12" Corpus Arm Left - Dual Taper, Leatherette No Charge

Page 5 of 8Rev 2009-4 8/24/2009 3:16:25PM



Required Items

I103342-99-0 4"x14" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103344-99-0 4"x16" Corpus Arm Left - Dual Taper, Leatherette No ChargeI103330-99-0 4"x10" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103332-99-0 4"x12" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103334-99-0 4"x14" Corpus Arm Left - Dual Taper, Black Fabric No ChargeI103336-99-0 4"x16" Corpus Arm Left - Dual Taper, Black Fabric No Charge


Select Options:














Cannot be ordered with 175 degree power recline seating systems. (I10482, I10485, I10488).

Accessories


Select Options:

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No ChargeI10405 Bodypoint Padded Hip Belt UniTrack (N/C) - Medium No ChargeI10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large 92.00 K0108I10408 Bodypoint Padded Hip Belt UniTrack - Large 155.00 K0108I100519-99-0 Positioning Belt Retractable 235.00 K0108I100600-99-0 Positioning Belt Retractable Long 255.00 K0108

Page 6 of 8Rev 2009-4 8/24/2009 3:16:25PM



Select Options:

I104131-99-0 Headrest for Ergo Back w/ Curved Mount Brkt - Leath 263.00 E0955Must also select PN I10552. This part consists of a leatherette headrest pad (10"W x 5"T) with a10"L slotted, curved mounting bracket.





7"W x 7"T Curved Pad. Must also select PN I10553.

I103071-99-0 UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) 125.00 E10208"W x 8"T Flat Pad. Must also select PN I10553.

I10553 Adj Removable - Amp Support Hardware (1 Each) 212.00 E1028Please indicate if you would like the amputation support mounted on the right or left side of the seatframe: Mount Amp Suppt on Right: ___________ Mount Amp Suppt on Left: ___________








Must also select PN I10551.I10551 Adj Removable - Trunk Support Hardware (Pair) 424.00 E1028I103651-99-0 Transfer Handles for UniTrack Accessory Rail 390.00I100578-99-0 Upper Extremity Support Small, Angle Adjustable 238.00 E0950






I103171-99-0 Roll Bar - X850 975.00

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Signed:

Printed Name:

Title:

Date:


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Documents

Permobil 2009 Order Forms FORMS/All_OrderForms_US.pdf · All order forms are effective July 1, ... Please indicate which armrest to mount midline below. I10428 Mount Midline Joystick