Customer Information

First Name

Last Name

Title

Company

Address

City

State

   Zip Code

Phone
Include Area Code

Fax
Include Area Code

Email

Ship To:

First Name

Last Name

Title

Company

Address

City

State

  Zip Code

Item

Quantity

Unit
Price

Total

SeatCase® (with Rear Brakes)

CALL

A C C E S S O R IE S

Leg Belts

CALL

Seat Belt/Chest Restraint

CALL

Seat Pad (1/8")

CALL

Carrying Bag
(limited quantities)

CALL

Subtotal

*Shipping
(within the United States)

TAX (if applicable)

$20.00 per chair
$ 4.00 per accessory

*SHIPPING (non-refundable

Total Enclosed

Payment Information

Payment Method

Check   Money Order
Purchase Order
Credit Card:
MasterCard     Visa

Credit Card Number

Expiration Date

Month    Year 

Full Name on Card

Are you authorized to use this credit card?
  Yes    No

Purchase Order No.