Please fill in this form and submit it to us.  This will help us identify your unique needs, so when we contact you we can discuss your options.  Thanks

NOTE: When filling in the fields on this form, use the tab key or mouse to move from field to field.  Using the Enter key will prematurely submit the form to us.

I prefer to be contacted by:

Email   

Phone  

Mail      

Customer Information

First Name 

Last Name

Address    

City                

State         

Zip Code       

Home Phone     Other Phone 

E-Mail      

Vehicle Information:

How much were you planning on spending for a vehicle? $

Already have financing?   (If not we can help arrange financing on new and used vehicles) 

Interested in a minivan

Interested in a full size van

Individuals dimensions in the wheelchair or scooter (please specify in inches or pounds)

Height of individual while seated in the wheelchair

Width of wheelchair from wheel to wheel

Weight of individual and wheelchair or scooter

Additional Equipment:

Drivers side transfer seat

Passenger side transfer seat

EZ-Lock

Q-Straints

Hand Controls

Spinner Knob

Tri_pin spinner knob

Low effort steering

Low effort braking

Auxilliary battery

Please provide a description of how the vehicle will be used and any additional information you want to convey.  Will the wheelchair user be driving it?  Do you want to be able to tow with it?  How many people will it need to seat?  Is it for local or long distance use?  If you see a new or used van your interested in include it as well.

 for example:

"I am interested in a wheelchair accessible vehicle for myself.  I will be towing a small pop up camper with it occasionally, and will need room for my wife and 2 children. I see you have a 1999 dodge grand caravan LX for sale the stock number is 08423-JAC-08413"  

You are visitor number since May 24, 2003

Page Last Updated September 14, 2007