This form is designed to be filled out using Adobe Acrobat. BT-X Order Form Update- 719 Date: Shipping Information PO #: _ Ship to:_ Shipping Phone: Shipping Notes:_ 00BTX Aluminum frame, fixed axle wheelchair 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- 2” (5.0cm) Taper from rear seat width to front seat width +$295 00SWT-2 Rear and Front Seat Widths- Seat Depth Measurement from front of backrest post to front edge of seat sling. Frame Depth 00FD Depth measurement in front of seat upholstery at knee bend. Standard Length Axle Brace Style 00ABS Style of Axle to Seat Connector Ergonomic Seat 00ES Measurement from front of backrest post to center of upward bend. None- No Ergonomic Seat ** ‘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) increment

Front Seat Height Measurement from floor to top of front seat rail. Rear Seat Height Front End Angle The angle from the floor to the down tube. Wheel Camber Wheel Camber is set at 2° □ 2° Measurement from floor to top of rear seat rail. Rear Axle Center of Gravity " This model has a fixed (non-adjustable) axle. Measurement from front of backrest post to center of axle. Rear Wheel Offset Measure from outside of backrest post to inside of tire. (Gap between wheel and post). Wheel Offset Wheel Offset Footrest Width Measurement from inside of footrest post to inside of opposite footrest post. Footrest...

Back Height Measurement from rear seat base to top of back. Back Angle The angle from the floor to the back rest tube. Open Loop Double Tube- +$125 Aluminum Plate- +$225 Carbon with Adjustable Width Flared Sides- +$595 Footrest Finish 02FF Satin Finish Mirror Polished-02FF01 -02FF02 □ Powder Coat Frame Color- +$165 Anodize Black- +$195 Custom Color Anodized- +$295 Unitine, Aluminum Silver O Black O Powder Coat Frame Color- Custom Color Anodized- +$295 Frog Legs Phase One (Ultra Sport), Aluminum- +$350 E1015R, E1015L | | Silver Black Frog Legs Phase 2 Hybrid, Aluminum/Carbon- +$495 E1015R, E1015L...

Chair Options and Accessories- continued Rear Wheels 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 Omit rear wheels- BYOW (Bring your own wheels) List wheel model, size, and tire you will be using with your chair05RW-OMIT Sun Zero G Wheel, black spokes, black hub- No Charge 05RW-SZG Spinergy Wire Wheel, silver spokes, black hub, 30 spokes- +$320 05RW-SWW Spinergy Spox, black spokes, silver hub, 18 spokes- +$695 05RW-SS For the wheel models below, please make spoke color choice below right Spinergy...

Chair Options and Accessories- continued Omit Wheel Locks □ Compact Composite Scissor Locks Push Locks Side Guards 09SG * Aluminum Side guards will be finished with the same finish and color as the main frame. Mounting Style- [^Carbon w/ fender, bolted- +$695 Mounting Style- None Aluminum- +$395 Mounting Style- □ Fixed (welded), non-folding- Backbar Style 11BB Rounded ‘Sport’ Back Bar- +$225 iibb-rb \n Back Upholstery 12BU Fabric Back (choose one) [^Tension Cord Padding Style (choose one)- | | Original- Nylon cloth over foam Sport- Spacer Fabric over Neoprene +$225 12BU-TSF * Includes Rear Velcro...

Multi Terrain Configuration 19MTC Multi Terrain Configuration- +$2195 Off Road Configuration 20ORC Optional BT-X Configurations The Beach Configuration is designed to work with the BT-X base model as an add-on to the existing chair. • 9.4” (24cm) x 4.8” (12.3cm) balloon casters, forward mounted • Quick-Connect caster assembly for easy assembly- no tools needed • Finish matches chair • 25” (559 ETRTO) x 4” (10.2cm) custom built rear wheel set w/ axle • Switch between Everyday Mode and Beach Mode with no tools required I | Anodized, silver - standard | | Natural Fit Hand Rims- Original Size +$375...

Frame Finish- Color Options Cerakote- Standard Finish- Included Anodized- Premium Finish- +$1695 * Cerakote is a Polymer-Ceramic Composite coating. * Colors and shades will look different than the samples below. * Starts with a polished frame followed by color anodizing for a glossy finish. * Colors and shades will look different than the samples below. Dewalt Yellow Gloss Black Corvette Yellow Graphite Black (Satin) Hunter Orange SOCOM Blue Stone Grey Steel Blue Bright Purple Battleship Grey Yellowish Orange Burnt Bronze Desert Sand Medium Blue Light Green Ridgeway Blue BlueGreen ANO-BLG Bazooka...