ORDER FORM
				Bill To: Facility/Company: Contact Person: Address: Phone: Fax: Email:
				Ship To: Check box if Shipping is same as Billing address Facility/Company: Contact Person: Address: Phone: Fax: Email:
				Model Price Quantity Amount Model 225 Wheelchair Recline (platform unit) 3,650.00 Model 225 Optional Headrest 150.00 Shipping 150.00 Model 125A Wheelchair Recline (clamp unit) 2,700.00 Model 125A Optional Headrest 150.00 Shipping 100.00 Total
										Tax: Balance Due:
				If you are Tax Exempt please email or fax a copy of certificate. Contact Info Page.
				Comments/ Additional Information