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ORDER FORM<br />
<strong>Breezy</strong> ® <strong>Moonlite</strong><br />
Failure to use an order form for a <strong>Breezy</strong> chair order may result in delay or<br />
wrong shipment. This form does not include electronic validation, please<br />
read all instructions carefully.<br />
Please send all orders to:<br />
Fax: +44 (0)1384 44 66 44<br />
Email: orders@sunmed.co.uk<br />
Sunrise Medical Ltd<br />
High Street, Wollaston, West Midlands, DY8 4PS, England<br />
www.sunrisemedical.com<br />
Standard Features:<br />
Graphite metallic frame colour Flip up composite footrest Seat depth 41cm<br />
Folding aluminium frame 8" Solid Castors Back height 43cm<br />
Nylon padded upholstery Integrated armrest, long pad Seat height front 48cm<br />
Half folding backrest Fixed height Push handles Seat Angle 5°<br />
Swing in/out legrest Positioning belt Max user weight 115Kg<br />
Attendant Brakes ( transit version ) Crash Tested Chair weight 11.8kg (Transit)<br />
Warranty is 2 years on frame and axles Chair weight 13.5kg (self propel)<br />
and 12 months on other parts<br />
How to measure:<br />
Seat Depth Seat Width Frame Length<br />
From front of seat sling to<br />
back of seat sling<br />
From outside seat rail tube to<br />
outside seat rail tube<br />
From outside rear frame to outside front<br />
frame<br />
Back Height<br />
From seat sling to top of<br />
backrest sling<br />
Prices:<br />
All prices are in Pounds Sterling and Euros<br />
and exclude VAT. For latest issue, please<br />
refer to www.sunrisemedical.com. Please<br />
consult Sunrise Medical with any queries<br />
you may have.<br />
OF-MOONLITE-EN-UK-03-10-2011-REV6<br />
Page 1 of 2
ORDER FORM<br />
<strong>Breezy</strong> ® <strong>Moonlite</strong><br />
Failure to use an order form for a <strong>Breezy</strong> chair order may result in delay or<br />
wrong shipment. This form does not include electronic validation, please<br />
read all instructions carefully.<br />
Please send all orders to:<br />
Fax: +44 (0)1384 44 66 44<br />
Email: orders@sunmed.co.uk<br />
Invoice to:<br />
Name:<br />
Street:<br />
Town:<br />
Postal Code:<br />
Country:<br />
Telephone:<br />
Fax:<br />
Ship to:<br />
Name:<br />
Street:<br />
Town:<br />
Postal Code:<br />
Country:<br />
Telephone:<br />
Fax:<br />
Order Date:<br />
Purchase Order (Repeat on all pages):<br />
Marked for:<br />
Sunrise Order No:<br />
BREEZY <strong>Moonlite</strong> - Transit - PACKAGE 1<br />
BREEZY <strong>Moonlite</strong> - Transit - PACKAGE 2<br />
BASE PRICE: £325<br />
QTY<br />
BASE PRICE: £325<br />
QTY<br />
Part Number - QPMLITE16TL<br />
Part Number - QPMLITE18TL<br />
<br />
16" Seat Width<br />
<br />
18" Seat Width<br />
<br />
12" Mag Rear Wheels<br />
<br />
12" Mag Rear Wheels<br />
<br />
Solid Tyres<br />
<br />
Solid Tyres<br />
TOTAL PRICE<br />
TOTAL PRICE<br />
BREEZY <strong>Moonlite</strong> - Self Propel - PACKAGE 3 BREEZY <strong>Moonlite</strong> - Self Propel - PACKAGE 4<br />
BASE PRICE: £346 QTY BASE PRICE: £346<br />
QTY<br />
Part Number - QPMLITE16SL<br />
Part Number - QPMLITE18SL<br />
16" Seat Width 18" Seat Width<br />
<br />
22" Solid spoked rear wheels & anodized<br />
aluminium handrim<br />
<br />
22" Solid spoked rear wheels & anodized<br />
aluminium handrim<br />
Quick release axle & solid tyres Quick release axle & solid tyres<br />
TOTAL PRICE<br />
TOTAL PRICE<br />
All prices are in Pounds Sterling and exclude VAT. For latest issue, please refer to www.sunrisemedical.com. Please consult Sunrise Medical with any queries you may have.<br />
OF-MOONLITE-EN-UK-03-10-2011-REV6<br />
Page 2 of 2
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