Information Request

• Name
• Address
• City
• State
• Country
• Zip/Postal Code
• Phone
• Email
• Preferred Method of Contact - email or phone
• Cushion Color - "standard" blue, black or "specialty" burgundy, hunter green, tan or other
• Thoracic Drop - included
• Thoracic Restraint Strap - included
• Do you think you will LEASE or PURCHASE?
• Are you aware of potential TAX INCENTIVES? - yes or no