This form is designed to be filled out using Adobe Acrobat. Ship to:_ Mark For: Provence: State: Shipping Phone: Shipping Notes: Frame Style | | Lasher Sport BT Wheelchair $4995 Magnesium Frame Wheelchair □ Lasher Sport BT-MG Wheelchair $5995 Axle Brace Style Style of Axle to Seat Connector ** ‘I’ Style post will be used if the space between the axle and seat tube is too small for the ‘V’ style axle brace. * 5 position axle is adjustable up to 1” (2.54cm) forward and 1” (2.54cm) backwards by half inch (1.3cm) increments. Axle may have a different shape depending on the rear seat height. | | Adjustable Axle with shock absorption. +1495 * Axle is freely adjustable from 1” (2.54cm) to 4.5"” (11.4cm). Axle may have a different shape depending on the rear seat height. Measurement from outside of seat tubes at rear of seat upholstery. Seat Width Taper 00SWT Measurement from outside seat tubes at front of seat upholstery. □ 1” (2.5cm) Taper from rear seat width to front seat width +$295 00SWT-1 Rear and Front Seat Widths- | 12” (5.0cm) Taper from rear seat width to front seat width +$295 00SWT-2 Rear and Front Seat Widths-

Frame Dimensions Continued Frame Depth Seat Depth Measurement from front of backrest post to front edge of seat sling. 00FD Depth measurement in front of seat upholstery at knee bend. Standard Length Ergonomic Seat 00ES Measurement from front of backrest post to center of upward bend. None- No Ergonomic Seat 4” (10.2cm) +$495 00ES-4 Front Seat Height Measurement from oor to top of front seat rail. Rear Seat Height Measurement from oor to top of rear seat rail. Front End Angle The angle from the oor to the down tube. Rear Axle Center of Gravity ** This model has a xed (non-adjustable) axle. Measurement...

Wheel Camber Wheel Camber is set at 2° Rear Wheel Offset Measure from outside of backrest post to inside of tire. (Gap between wheel and post). Footrest Width Measurement from inside of footrest post to inside of opposite footrest post. Footrest Height Measurement from floor to top of front of footrest. (adjustable) Back Height Measurement from rear seat base to top of back. Back Angle The angle from the floor to the back rest tube. Chair Options and Accessories Footrest Style 01FS Open Loop Double Tube- +$125 Aluminum Plate- +$225 Angle Adjustable Aluminum- $295 Carbon with Adjustable Width...

Footrest Finish Powder Coat Frame Color 02FF03 Front Caster Forks Custom Color Anodized- +$295 Unitine, Aluminum Black Custom Color Anodized- +$295 Powder Coat Frame Color- +$150 03CF03 Frog Legs Phase One (Ultra Sport), Aluminum- +$350 Frog Legs Phase 2 Hybrid, Aluminum/Carbon- +$495 Unitine Fork Phase One Fork (Shock Absorbing) Front Casters Epic Wide, Soft Roll, Aluminum Hub Epic Narrow, Firm Roll, Aluminum Hub 04FC02 Select Caster Size Select Caster Size Hand Rims (Shock Absorbing) Hard Anodized- No Charge Natural Fit Q-Grip- Option- +$295 Choose Finish- * Rubber Coated hand rim 06HR-NFQ...

Chair Options and Accessories- continued Rear wheel size * Rear wheel size is required even if no wheel option is chosen. Chair will be built to the wheel size selected. Rear wheel model Vapor 13 Aluminum- Included Rim Color Choice I I Black Q Olive Green Classic Glossy Black Classic Matte Black Hex Matte Black Hex Glossy Black Hub Color Choice I | Black Q Olive Green □ Gold □ Turquoise I I Orange Q Blue Omit rear wheels- BYOW (Bring your own wheels) List wheel model, size, and tire you will be using with your chair- Spinergy Spox, black spokes, silver hub, 18 spokes- +$695 For the wheel models...

Omit Wheel Locks 08WL-O Chair Options and Accessories- continued m Push Locks- +$295 Side Guards 09SG * Aluminum Side guards will be finished with the same finish and color as the main frame. None Aluminum- +$395 09SG-NO Mounting Style- Carbon- +$595 Carbon w/ fender, bolted- +$695 Mounting Style- Mounting Style- Backrest Style iobs □ Folding, non-locking 10BS-FNO Folding, locking- +$225 iobs-fl Fixed (welded), non-folding- +$295 iobs-w Backbar Style iibb~1 Classic Back Bar 1—1 iibb-cb Rounded ‘Sport’ Back Bar- +$225 iibb-rb Back Upholstery 12BU Fabric Back (choose one) Rigid Back Q Tension Cord...

Powder Coat- Standard Finish- Included * Powder coat is a baked on finish. * Colors and shades can look different than the samples below. Powder Coat- Premium Finish- +$495 * Powder coat is a baked on finish. * Colors and shades can look different than the samples below. Illusion True Copper PMB-10044 * Ultra Illusion Green . PMB-5346 \ Illusion Copper Plua^ PMB-5043 Lollypop Blue Ford Dark Blue PSB-4624 Flat Shocker Yellov PPB-6524 * _iLazer Polka Pink □ Illusion Sour Apple