M300 Corpus HD - Permobil

M300 Corpus HDDealer Information* Contact:______________________________Dealer Code:______________________________* Dealer Name:______________________________Address:______________________________* City:______________________________* Province:______________________________* Phone#:______________________________* Fax#:______________________________PO#:______________________________Email Address:______________________________Client InformationPermobil recommends that the client is evaluated by acertified rehab specialist.* First Name:______________________________* Last Name:______________________________Diagnosis:______________________________Funding Source:______________________________Client Age:______________________________Client Measurements* Weight:_______________________________*Height:_______________________________A) Top of Shoulders:_______________________________B) Chest Depth:_______________________________C) Chest Width:_______________________________D) Seat Depth:_______________________________E) Top of Head:_______________________________F) Elbow to Hand:_______________________________G) Seat Pan to Elbow:_______________________________H) Hip Width:_______________________________*I) Knee to Foot:_______________________________Display ADP Codes on order/quote:Three column pricing on order/quote:Please send order/quote to fax#: (800) 231-3256Email to: sales@permobil.comPermobil Ltd.4 - 75 Mary St.Aurora, OntarioL4G 1G3Tel: (888) 726-9330CAN Fax: (905) 726-9990US Fax: (800) 231-3256www.permobil.comPrices effective November 4, 2013 and payable in Canadian dollars.

M300 Corpus HDChair Model and ColorsCANADIAN MSRP PRICE LISTPart Number DescriptionMSRP - CAI10908 M300 Base Corpus HD - SPO10,036.29Price Includes: M300 Power HD Base Set Up For One Power Seat Function, ShockAbsorbing Suspension System, R-net Controller, Tie-Down Hardware For Strap Systems,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or PneumaticTires Below. 5.0mph, Weight Capacity = 450 lbs.I105799-99-0 M300 Base Corpus HD - MPO10,036.29Price Includes: M300 HD Power Base Set Up For Multiple Power Seat Functions, ShockAbsorbing Suspension System, R-net Controller, Tie-Down Hardware For Strap Systems,Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or PneumaticTires Below. 5.0 mph, Weight Capacity = 450 lbs.CHOOSE DRIVE TIRES:Part Number DescriptionI103499-99-0Tri-Spoke Split Rim w/ Flat Free Drive Tire 3x8"I103498-99-0 Tri-Spoke Split Rim w/ Pneumatic Tires - 3x8"MSRP - CANo ChargeNo ChargeOPTIONAL DRIVE TIRES:Part Number DescriptionMSRP - CAI10782 Tri-Spoke Split Rim w/ Snow Tire Pneumatic 3x8"456.96Snow tires are designed for use in cold weather conditions. The nylon compound in thesetires remains flexible at low temperatures, but wears more easily. Therefore, the snow tires(sold as wheel assemblies) are not recommended for year-long use and must be orderedalong with standard drive wheels.CHOOSE SHROUD COLOR:Part Number DescriptionI105885-99-0M300 HD Shroud - Onyx BlackI105881-99-0M300 HD Shroud - Platinum SilverI105887-99-0M300 HD Shroud - Sublime GreenI106169-99-0M300 HD Shroud - Cobalt BlueI106171-99-0M300 HD Shroud - Phantom GreyI106159-99-0M300 HD Shroud - Pop Star PinkI106170-99-0M300 HD Shroud - Purple RainI106160-99-0 M300 HD Shroud - Volcano RedMSRP - CANo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeCHOOSE HUBCAP COLOR:Part Number DescriptionMSRP - CAMatch Hubcap Color to Shroud: _____Note: Hub caps will be matched to shroud color if no selection is made.I10871Solid Color Hub Cap - PairNo ChargePlatinum Silver: _____ Onyx Black: _____ Cobalt Blue: _____ Phantom Gray: _____Pop Star Pink: _____ Volcano Red: _____ Purple Rain: _____ Titan Blue: _____Sublime Green: _____ Crystal Blue: _____ Vintage Wine: _____ Extreme Yellow: _____Chili Pepper Red: _____ Green Metallic: _____Base OptionsMUST CHOOSE EITHER SEAT ELEVATOR OR FIXED SEAT TUBE:Part Number DescriptionMSRP - CAI105875-99-0 HD Power Adjustable Seat Height - 8" Travel3,248.19I105880-99-0 HD Seat Tube FixedNo ChargeMUST CHOOSE BATTERIES:Part Number DescriptionMSRP - CAIM24 SLD G FT Batteries, Grp 24 (72Ah) Sealed LA/Gel, Installed840.48IM34 SLDG Batteries, Grp 34 (60Ah) Sealed LA/Gel, Installed830.28ADP $10,036.29 CodeADP CodeADP $456.96 CodeADP CodeADP CodeADP $3,248.19 CodeADP $840.48 CodeRev 2013-4 11/4/2013Page 2 of 16

M300 Corpus HDBase OptionsCHOOSE SEAT PAN TO FLOOR HEIGHT:Part Number DescriptionI105878-99-0Set Seat to Floor Height at 18"I105877-99-0Set Seat to Floor Height at 19"I105876-99-0 Set Seat to Floor Height at 20"CANADIAN MSRP PRICE LISTMSRP - CANo ChargeNo ChargeNo ChargeOPTIONAL ITEMS:Part Number DescriptionMSRP - CAI105428-99-0 Enhanced Steering Perform Unit (ESP), R-net1,313.76Recommended item with switched drive inputs for improved tracking.I105297-99-0 LED Light Kit for M300 / M400 w/ R-net Electronics1,004.70I10715 Compact Laptop Ventilator Tray - Corpus 3G Seat1,465.74Mounts to rear of Corpus 3G backrest hinge. Accommodates Pulmonetic Systems /CareFusion LTV Series and similar sized Laptop Ventilators. The tray is 330mm Tall,adjustable Width between 200mm - 330mm, and adjustable Depth between 50mm - 165mm.Overall backrest angle limited to 150° when mounting this ventilator tray. Custom Option.I10787 Battery Tray for Laptop Ventilator Tray234.60Mounts to rear of Laptop Ventilator Tray. Measures 290mm W x 170mm H x 42mm D.Accomodates Pulmonetic Systems Lithium-Ion Battery Pack, CareFusion SprintPack BatterySystem, or Richardson PowerTech Vent Power Center. Custom Option.I10788 O2 Holder for Laptop Ventilator Tray331.50Mounts to Left or Right Side of Laptop Vent Tray. O2 Holder is 175mm Tall. Width infinitelyadjustable 90mm - 170mm. Depth infinitely adjustable 95mm - 125mm. Custom Option.ID51113 Programming Key for R-net - Permobil Version456.96Joystick OptionsCHOOSE JOYSTICK TYPE:Part Number DescriptionMSRP - CAPLEASE NOTE:For all remote joystick modules shown below, you must also select an expandable controller.For additional input devices, refer to Alterative Drive Systems Section.I105246-99-0R-net LED Remote Joystick ModuleNo ChargeID51185 R-net Remote Colour JS w/ Mono Jacks, No Lights1,570.80ID51188 R-net Remote Colour JS w/ Toggle Switches, No Lghts1,780.92ID51153 R-net Remote Colour JS w/ Mono Jacks, Lights1,570.80ID51149 R-net Remote Colour JS w/ Toggle Switches, Lights1,734.00I105700-99-0 R-net Remote Color JS w/ Lights, Heavy Duty Gimble1,779.90Heavy-Duty modification enables gimble to hold up to extreme operating forces. Reinforcedhousing is attached to a standard Color LCD R-net Joystick. 3" long joystick knob has 3/4"I103814-99-0 diameter. Not compatible with alternative joystick handles.Compact Advanced Joystick for R-net1,734.00Compact sized joystick that does not contain an LCD Display. Contains two mono jacks formode & on/off. Does NOT contain a wrist support pad. If you want a wrist support pad,please select I10621, below.I10621 Add Wrist Pad to Compact Joystick Advanced220.32CHOOSE JOYSTICK HANDLE TYPE:Part Number DescriptionMSRP - CAI10045Cone Shaped Joystick Knob - StandardNo ChargeI100960-99-0 Chin Cup For Joystick Knob104.04I100961-99-0 "T" Handle For Joystick Knob153.00I100962-99-0 "Large Ball" For Joystick Knob104.04I100963-99-0 "Softball" For Joystick Knob139.74I100964-99-0 "Mushroom" For Joystick Knob139.74I100965-99-0 "Stick" For Joystick Knob139.74I105442-99-0 1.75" Black Foam Ball For Joystick Knob104.04ADP CodeADP $1,313.76 CodeADP CodeWEX1WEX1ADP CodeRev 2013-4 11/4/2013Page 3 of 16

M300 Corpus HDCANADIAN MSRP PRICE LISTJoystick OptionsCHOOSE JOYSTICK HANDLE TYPE:Part Number DescriptionMSRP - CAIPC101B Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft133.62IPC102B Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft133.62IPC107B Bodypoint J/S Handle Dome Shaped, Rubber133.62ADP $133.62 CodePart Number DescriptionMSRP - CAI10664Joystick Mount Right - FixedNo ChargeI10665Joystick Mount Left - FixedNo ChargeI103820-99-0 Retractable Joystick Mnt Right - R-net, VR2393.72I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2393.72I105210-99-0 Mount Standard Joystick on Corpus 3G Back Hinge273.36Standard R-net Joystick is mounted to backrest hinge. Can be chosen instead of PNI105408-99-0. Mount on Left: _____ Mount on Right: _____I101260-99-0 Midline Control Mount - Pilot+ & R-net341.70Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____I106266-99-0 Stealth Gatlin Midline Mount - 8 Position600.78Features eight locking positions each 45° apart. Adjustments are made by pulling out onmounting arm and rotating to desired angle. Joystick bracket sold separately (select from thebrackets listed below). Please indicate if you want it mounted on left or right armrest:Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____I106265-99-0 Stealth Gatlin Midline Mount - 2 Position600.78Designed for easy swing away. Mount can be set to swing from horizontal to 95° or fromhorizontal to 180°. Joystick bracket sold separately (select from the brackets listed below).Please indicate if you want it mounted on left or right armrest:Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____I106267-99-0 Stealth Gatlin Bracket for R-net/Compact JS Adv246.84I106295-99-0 Stealth Gatlin Bracket for Compact Joystick246.84I106296-99-0 Stealth Gatlin Bracket for Mini Joystick246.84I106297-99-0 Stealth Gatlin Swivel Bracket for Omni280.50I10842 PermoFix Joint for Gatlin (0027-7027a)246.84Includes a shim that allows the PERMOFix Joint to be mounted on the 1/2" Stealth Gatlinarm. Provides an adjustable mount for a Mini Joystick or Compact Joystick.I106268-99-0 Stealth Height Adjustable Mount219.30Replaces standard UT panel bracket. Provides 1.75" of height adjustability to all Permobiljoystick mounts and Stealth Gatlin Midline mounts.ADP CodeWEPMWEPMWE3DPart Number DescriptionMSRP - CAI10411Expandable Controller - R-netNo ChargeMust be ordered with the expandable/remote joysticks (PN: I10410, I103544-99-0, ID51040,ID51108, ID51042, and I103814-99-0).I10513Harness for Expandable ControllerNo ChargeMust be ordered with any Expandable Controller (I10411 or I10450)I105225-99-0 Co-Pilot Attendant Control R-net - Corpus 3G4,386.00I105408-99-0 Attendant Control R-net - Corpus 3G1,139.34I106057-99-0 R-net BT Mouse Module919.02I10582 Output Module (IOM) for R-net Control System1,523.88This allows a user to control an external device (ex: Communication Device, ECU, DoorOpener, etc.) through the drive input (JSM, Head Array, etc.). One output module is requiredfor each separate external device to be controlled. Up to three output modules can beinstalled on one wheelchair.Seating SystemCHOOSE SEATING SYSTEM:Part Number DescriptionMSRP - CAADP CodeADP CodeRev 2013-4 11/4/2013Page 4 of 16

M300 Corpus HDSeating SystemCANADIAN MSRP PRICE LISTCHOOSE SEATING SYSTEM:Part Number DescriptionMSRP - CAPLEASE NOTE:Weight Limit 450lbs. For the Corpus HD Seat on the M300, there is a half speed drive limitwhen the Total Backrest Angle (TBA) > 135° and a drive inhibit at 150° of TBA. There is alsoa drive inhibit at 20° of tilt.I10910 HD Seat w/ No Tilt & Manual Recline7,399.59I10911 HD Seat w/ No Tilt & 150° Power Recline8,358.90I10912 HD Seat w/ 45° DuraCore Tilt & Manual Recline8,072.79I10913 HD Seat w/ 45° DuraCore Tilt & 150° Power Recline12,672.99Seating System OptionsCHOOSE SEAT FUNCTION CONTROL TYPE:Part Number DescriptionMSRP - CAI10418Single Seat Function Control Switch for R-netNo ChargePlease choose either Push Buttons or Toggle Switches below.I10419 Single Seat Function Control Kit for R-net1,447.38For operation of a single seat function through the wheelchair electronics via the drive controland/or ICS Switchbox. Order with R-net Controller or remote joystick options. Pleaseindicate below if you want push buttons or toggles on the ICS Switchbox.I10585 Multiple Seat Function Control Kit for R-net2,411.28MUST be selected if ordering two or more seat functions. This device is used to operate twoor more seat functions through the wheelchair electronics via the drive control and/or ICSswitch box. Order with R-net electronics or remote joystick options. Please indicate below ifyou want push buttons or toggles on the ICS Switchbox.CHOOSE PUSH BUTTONS OR TOGGLES:Part Number DescriptionMSRP - CAI102798-99-0Push Buttons on Seat Function Control KitNo ChargeI102799-99-0 Toggle Switches on Seat Function Control Kit257.04I105409-99-0 Do Not Install ICS Switchbox, Send as PartNo ChargeCHOOSE MOUNTING POSITION OF ICS SWITCHBOX:Part Number DescriptionMSRP - CAI10626Mount ICS Switchbox onto R-net Joystick BracketNo ChargeICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this itemI104651-99-0is selected, the ICS Switchbox will swing away with the Joystick Module.Mount ICS Switchbox onto ArmrestNo ChargeI106256-99-0 Mount on Left: _____ Mount on Right: _____Mount ICS Switchbox on Backrest144.84Mount on Left: _____ Mount on Right: _____ADP CodeADP CodeSEC1P1005ADP CodeADP CodeOPTIONAL ITEMS:Part Number DescriptionMSRP - CAI104196-99-0 ICS Alternative Switchbox for R-net Electronics1,139.34Not available with VR2 Electronics. Seat function interface box which accommodates up to 8momentary switches. Provides an additional method to accessing the seat functions. Youmust still order the Multiple Seat Function Control Kit if ordering this part. 1/8" mini-monoswitches not included.I104769-99-0 Remote Stop System - All Electronics1,086.30Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on thewheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must beused together. Custom charge may be required if ordering with a low backrest height or apediatric wheelchair. If ordering Remote Stop System with a K450, push handles must alsobe selected.I10750 Memory Seat Program, Corpus 3G w R-net105.06ADP $1,139.34 CodeRev 2013-4 11/4/2013Page 5 of 16

M300 Corpus HDSeating System OptionsCANADIAN MSRP PRICE LISTOPTIONAL ITEMS:Part Number DescriptionMSRP - CAI106209-99-0 Legrest Movement Linked to Recline Electronically44.00Power Legrest will raise when Power Recline moves backward and will lower when backmoves forward. If Power Legrest is operated, Power Recline will NOT automaticallyreposition. Feature works through ICS Switchbox and Driver Control.I10898Enable Independent Repositioning ModeNo ChargeEnables the Corpus 3G Independent Repositioning Mode through all standard Driver ControlInput Devices. If a Switchbox Layout with memory is chosen, IRM will be accessible throughthe ICS Switchbox. For Alternative Drive Controls, an ICS Switchbox may be required to useIRM.Backrest OptionsCHOOSE FIXED OR SLIDING BACKREST KIT:Part Number DescriptionMSRP - CAI105871-99-0Sliding Backrest Kit - 5" Mechanical ShearNo ChargeI105869-99-0 Fixed Backrest Kit - No Mechanical Shear33.66CHOOSE BACKREST TYPE:Part Number DescriptionMSRP - CABACKREST HEIGHT NOTE:Backrest heights are measured from the seat pan to the top of the backrest shell with thebackrest set at 90°.I106016-99-0 Corpus HD Ergo Backrest - 20"W x 21"T (C3GERGBCA)1,007.56I106017-99-0 Corpus HD Ergo Backrest - 22"W x 21"T1,007.56I106018-99-0 Corpus HD Ergo Backrest - 24"W x 21"T1,007.56I10915Solid Back 20"W x 21"T - Corpus HD SeatNo ChargeI10916Solid Back 22"W x 21"T - Corpus HD SeatNo ChargeI10917Solid Back 24"W x 21"T - Corpus HD SeatNo ChargePLEASE NOTE:All taller backrests listed below include: lumbar pad, a UT rail mounted at the top for lateraladjustment of the headrest, and split backrest feature with height adjustment in 1"increments. Please indicate below where you want the height set at so that a properly sizedbackrest cushion can be provided.I106019-99-0 Corpus HD Ergo Back -20"W x 24 - 29"T (C3GERGBCA)1,007.56I106020-99-0 Corpus HD Ergo Back -22"W x 24 - 29"T1,007.56I106021-99-0 Corpus HD Ergo Back -24"W x 24 - 29"T1,007.56I10919Solid Back 20"W x 24 - 29"T - Corpus HD SeatNo ChargeI10920Solid Back 22"W x 24 - 29"T - Corpus HD SeatNo ChargeI10921Solid Back 24"W x 24 - 29"T - Corpus HD SeatNo ChargeSet Backrest at 24" _____Set Backrest at 25" _____Set Backrest at 26" _____Set Backrest at 27" _____Set Backrest at 28" _____Set Backrest at 29" _____ADP Code $44.00ADP CodeADP CodeCHOOSE BACKREST CUSHION:Part Number DescriptionMSRP - CAI10659Leatherette Cushion - Corpus 3G Ergo BackNo ChargeI10660 Black Mesh Cushion - Corpus 3G Ergo Back46.92I105117-99-0 Omit Backrest CushionNo ChargeOPTIONAL ITEMS:Part Number DescriptionMSRP - CAADP CodeADP $310.08 CodeRev 2013-4 11/4/2013Page 6 of 16

M300 Corpus HDBackrest OptionsCANADIAN MSRP PRICE LISTOPTIONAL ITEMS:Part Number DescriptionMSRP - CAI10725 Split Backrest Cushion - Corpus 3G310.08Custom Option.Seat SizingCHOOSE SEAT WIDTH SETTING:Part Number DescriptionI105859-99-0Set Seat Width at 19"I105860-99-0Set Seat Width at 21"I105861-99-0Set Seat Width at 23"I105862-99-0 Set Seat Width at 25"MSRP - CANo ChargeNo ChargeNo ChargeNo ChargeCHOOSE SEAT DEPTH:Part Number DescriptionMSRP - CAPLEASE NOTE:Odd numbered seat depths can be made 1" shorter without any additional parts. Forexample, a 21"D seat can also be set at 20"D.I105863-99-0Corpus HD Seat Depth 19"No ChargeI105864-99-0Corpus HD Seat Depth 20"No ChargeI105865-99-0Corpus HD Seat Depth 21"No ChargeI105866-99-0Corpus HD Seat Depth 22"No ChargeI105868-99-0Corpus HD Seat Depth 23"No ChargeI105856-99-0Corpus HD Seat Depth 24"No ChargeI105857-99-0 Corpus HD Seat Depth 25"No ChargeCHOOSE SEAT CUSHION:Part Number DescriptionMSRP - CAI10651 Corpus 3G Ergo Seat Cush - Leatherette (C3GERGSCA)512.00I10652 Corpus 3G Ergo Seat Cush - Black Mesh (C3GERGSCA)512.00I105118-99-0 Omit Seat CushionNo ChargeArmrest OptionsCHOOSE ARMBAR MOUNTING POSITION:Part Number DescriptionI106022-99-0Set Armbar at 20"W Between Armrests:____I106023-99-0Set Armbar at 21"W Between Armrests:____I106024-99-0Set Armbar at 22"W Between Armrests:____I106025-99-0Set Armbar at 23"W Between Armrests:____I106026-99-0Set Armbar at 24"W Between Armrests:____I106027-99-0 Set Armbar at 25"W Between Armrests:____MSRP - CANo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeCHOOSE ARMREST HEIGHT MOUNTING POSITION:Part Number DescriptionMSRP - CAI10923 Height Adjustable Amrests353.43I10924Height Adjustable Amrests - NCNo ChargeSET ARMREST HEIGHT AT:____Corpus HD Armrests are infinitely adjustable from 8" - 16", measured from the seat pan to thetop of the arrmrest pad. No additional parts are needed to get this full range of adjustment. Inone inch increments (ex: 8", 9", etc.), please indicate where you would like the armrests set.CHOOSE ARMREST PAD RIGHT:Part Number DescriptionI105104-99-04"x13" Corpus 3G Armrest Pad Right - LeatheretteI105997-99-0 4"x16" Corpus HD Armrest Pad Right - LeatheretteRev 2013-4 11/4/2013Page 7 of 16MSRP - CANo ChargeNo ChargeADP $310.08 CodeADP CodeADP CodeADP $524.28 CodeADP CodeADP $353.43 CodeADP Code

M300 Corpus HDArmrest OptionsCANADIAN MSRP PRICE LISTCHOOSE ARMREST PAD RIGHT:Part Number DescriptionMSRP - CAI105999-99-04"x18" Corpus HD Armrest Pad Right - LeatheretteNo ChargeI106047-99-04"x13" Corpus HD Armrest Pad Right - Black FabricNo ChargeI105993-99-04"x16" Corpus HD Armrest Pad Right - Black FabricNo ChargeI105995-99-04"x18" Corpus HD Armrest Pad Right - Black FabricNo ChargeI106488-99-0 4"x13" Corpus 3G Arm w/ Stealth Gel Pad - Right170.60I106571-99-0 4"x16" Corpus HD Arm w/ Stealth Gel Pad - Right176.65I106281-99-0 4"x18" Corpus HD Arm w/ Stealth Gel Pad - Right182.20CHOOSE ARMREST PAD LEFT:Part Number DescriptionMSRP - CAI105102-99-04"x13" Corpus 3G Armrest Pad Left - LeatheretteNo ChargeI105996-99-04"x16" Corpus HD Armrest Pad Left - LeatheretteNo ChargeI105998-99-04"x18" Corpus HD Armrest Pad Left - LeatheretteNo ChargeI106046-99-04"x13" Corpus HD Armrest Pad Left - Black FabricNo ChargeI105992-99-04"x16" Corpus HD Armrest Pad Left - Black FabricNo ChargeI105994-99-04"x18" Corpus HD Armrest Pad Left - Black FabricNo ChargeI106489-99-0 4"x13" Corpus 3G Arm w/ Stealth Gel Pad - Left170.60I106570-99-0 4"x16" Corpus HD Arm w/ Stealth Gel Pad - Left176.65I106303-99-0 4"x18" Corpus HD Arm w/ Stealth Gel Pad - Left182.20OPTIONAL ITEMS:Part Number DescriptionMSRP - CAI105463-99-0 Corpus 3G Arm Trough Adapter 1" - Pair302.94For aftermarket armrest pads. Please indicate below if they should be installed or on chairI105462-99-0 sent as parts.Corpus 3G Arm Trough Adpater 7/8" - Pair302.94For aftermarket armrest pads. Please indicate below if they should be installed or on chairsent as parts.Install Arm Trough Adapters: _____Send Arm Trough Adapters as Parts: _____I100671-99-0 Armrest Pouch-Right210.12I100672-99-0 Armrest Pouch-Left210.12I10705 Corpus 3G Armrest Side Support - Right Outer225.42Custom Option. Leatherette Pad (2"T x 8.5"L). Not compatible with Stealth Elbow Support,I10706 except when ordered with an 18" armrest.Corpus 3G Armrest Side Support - Left Outer225.42Custom Option. Leatherette Pad (2"T x 8.5"L). Not compatible with Stealth Elbow Support,I10707 except when ordered with an 18" armrest.Corpus 3G Armrest Side Support - Right Inner225.42Custom Option. Leatherette Pad (2"T x 8.5"L). Recommend 2" wider width between theI10708 armrest to ensure armrests will flip-up.Corpus 3G Armrest Side Support - Left Inner225.42Custom Option. Leatherette Pad (2"T x 8.5"L). Recommend 2" wider width between theI106264-99-0 armrest to ensure armrests will flip-up.Stealth 3" x 10" Elbow Support, 3G/HD - Right145.86Must also select PN I10881.I106263-99-0 Stealth 3" x 10" Elbow Support, 3G/HD - Left145.86Must also select PN I10882.I10881 Adjustable Elbow Support Hardware - Right246.84I10882 Adjustable Elbow Support Hardware - Left246.84Legrest OptionsADP CodeADP CodeADP $302.94 CodeRev 2013-4 11/4/2013Page 8 of 16

M300 Corpus HDCANADIAN MSRP PRICE LISTLegrest OptionsCHOOSE LEGREST TYPE:Part Number DescriptionMSRP - CA ADP CodeI106053-99-0Corpus HD Manual Adj Legrest ElevationNo ChargeI106052-99-0 Power Elevating Center Mount Legrests - 175°3,696.99Includes mechanical articulation.CHOOSE FOOTPLATE STYLE:Part Number DescriptionMSRP - CAI106008-99-02pc Wide Corpus HD Footplates - 9"D x 7.5"WNo ChargeI106009-99-0 2pc Extra Wide Corpus HD Footplates - 9"D x 9"W247.96FOOTPLATE HEIGHT POSITION:Part Number DescriptionMSRP - CASET FOOTPLATE HEIGHT AT:____This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrestassembly is at 90° DO NOT INCLUDE CUSHION THICKNESS IN YOUR MEASUREMENT.In one inch increments, please indicate desired footplate height. NOTE: Standard Corpus HDfootplate height range is 6" - 18". Calf Pads are not available at heights less than 10".CHOOSE LATERAL FOOTPLATE ROTATION OPTIONS:Part Number DescriptionMSRP - CAI106006-99-0Lateral Footplate Rotation - FixedNo ChargeI106007-99-0 Lateral Footplate Rotation - Enabled32.54OPTIONAL ITEMS:Part Number DescriptionMSRP - CAI106190-99-0UT Calf Support Kit (A) w Mesh Cover & Adj HardwareNo Charge5.5"W x 6"T Pad. Compatible with footplate heights of 10" - 18".I106188-99-0 UT Calf Support Kit (H) w Mesh Cover & Adj Hardware366.897"W x 7"T Curved Pad. Compatible with footplate heights of 11" - 18".I106186-99-0 UT Calf Support Kit (D) w Mesh Cover & Adj Hardware366.898"W x 8"T Pad. Compatible with footplate heights of 12" - 18".I106225-99-0 Stealth Gel Pads - Wide Footplates (Pair)368.50I106224-99-0 Stealth Gel Pads - Extra Wide Footplates (Pair)379.50AccessoriesMUST CHOOSE POSITIONING BELT:Part Number DescriptionMSRP - CAI10400Bodypoint Non-Padded Hip Belt, UniTrack - MediumNo ChargeI10404 Bodypoint Padded Hip Belt UniTrack - Medium125.46I10940Bodypoint Non-Padded Hip Belt, UniTrack - LargeNo ChargeI10408 Bodypoint Padded Hip Belt UniTrack - Large171.36I10935 Bodypoint Padded Hip Belt UniTrack - Extra Large233.38I100519-99-0 Positioning Belt Retractable259.08I100600-99-0 Positioning Belt Retractable Long281.52OPTIONAL ITEMS:Part Number DescriptionMSRP - CAI105291-99-0 Headrest Corpus 3G Back, 10"W x 5"T, Leatherette540.60Must also select PN I10552.I105290-99-0 Headrest Corpus 3G Back, 10"W x 5"T, Black Fabric540.60Must also select PN I10552.I105212-99-0 Headrest Corpus 3G Back, Ergo Shape, Black Fabric446.76Must also select PN I10552.ADP CodeADP CodeADP CodeADP CodeADP CodeADP $540.60 CodeRev 2013-4 11/4/2013Page 9 of 16

M300 Corpus HDAccessoriesCANADIAN MSRP PRICE LISTOPTIONAL ITEMS:Part Number DescriptionMSRP - CAI10180 Universal Headrest Adapter217.26Will be sent as part if ordering sling back upholstery or a Stealth Headrest on a Corpus 3G.Please Note: Recline is limited to 160° or less (depending on backrest height) when orderinga Universal Headrest Adapter on a 23" or 24" tall Corpus 3G backrest.I10552 Adj Removable - Headrest Hardware (1 Each)115.26I103070-99-0 UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each)325.387"W x 7"T Curved Pad. Must also select PN I10553.I103071-99-0 UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each)325.388"W x 8"T Flat Pad. Must also select PN I10553.I10553 Adj Removable - Amp Support Hardware (1 Each)115.26Please indicate if you would like the amputation support mounted on the right or left side ofthe seat frame:I106104-99-0 Mount Amp Suppt on Left: _____ Mount Amp Suppt on Right: _____UT Hip Suppt (B) w/ Mesh Cover - High (Pair)264.794.5"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I106103-99-0 UT Hip Suppt (A) w/ Mesh Cover - High (Pair)264.796"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair)430.446.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I103095-99-0 UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair)430.448"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I102977-99-0 UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair)430.4412"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.I10550 Adj Removable - Thigh Support Hardware (Pair)115.26I10783 Hand Heater Kit with Buddy Button895.56Kit includes Hand Heater (2"H x 1.5"W x 2.75"D), Buddy Button, Power Cable with XLR Plugand PERMOfix Mounting Adapter. Heater has three temp/fan speed settings. For bestresults, a hand cone (I10784 or I10785) is recommended to trap heat around the user'shand(s). To ensure best positioning for the user, heater will NOT be mounted when chair isI10784 received.One-Hand Cone Kit with PERMOfix Mounting Set517.14Clear plastic dome (5.5"W x 13.5"L x 8"H) with forearm opening at one end. Kit includesPERMOfix mounting hardware to attach cone to end of armrest. To ensure best positioningI10785 for the user, cone will NOT be mounted when wheelchair is received.Two-Hand Cone Kit with Mounting Pins406.98Clear plastic triangular dome (15"W x 12.5"L x 8"H) with two forearm openings. Use withUpper Extremity Support is recommended. Kit includes four pins to secure cone to traysurface. Pins remove without tools for easy transfers. To ensure the best positioning for theuser, cone will NOT be mounted.I105260-99-0 Transfer Handles, Corpus 3G Seat446.76I105292-99-0 Push handles, Corpus 3G Seat393.72I106210-99-0 Self-Leveling Cup Holder78.54I103044-99-0 Cup/Cell Phone Holder68.34I105805-99-0 Medical Necessities Bag Hooks83.64Please Note: Recline is limited to 165° or less (depending on backrest height) when orderingI102059-99-0 with 23" or 24" tall Corpus 3G backrest.Medical Necessities Bag236.64Includes hardware to attach bag to backrest. Please Note: Recline is limited to 165° or lessI105144-99-0 (depending on backrest height) when ordering with a 23" or 24" tall Corpus 3G backrest.Bodypoint Monoflex Large Chest Support Belt Kit163.2021.5"L x 4.5"W Pad Size. Item will be shipped as parts.I105143-99-0 Bodypoint Monoflex Medium Chest Support Belt Kit163.2018.25"L x 4"W Pad Size. Item will be shipped as parts.I105145-99-0 Bodypoint Monoflex X-Lrge Chest Support Belt Kit163.2024.5"L x 5"W Pad Size. Item will be shipped as parts.Page 10 of 16Rev 2013-4 11/4/2013ADP $217.26 CodeSEHND0020SEFND0005SEFND0005SELND0015SELND0015SELND0015

M300 Corpus HDAccessoriesCANADIAN MSRP PRICE LISTOPTIONAL ITEMS:Part Number DescriptionMSRP - CAI106197-99-0 Upper Extremity Support Angle Adjustable 20"W381.48I106198-99-0 Upper Extremity Support Angle Adjustable 22"W403.92I10556 Adj Removable - Tray Hardware (1 Each)115.26I105224-99-0 Oxygen holder288.66Stealth AccessoriesI105223-99-0 Crutch holder299.88OPTIONAL ITEMS:Part Number DescriptionMSRP - CAI106291-99-0 Stealth Comfort Plus Headrest - 8"W365.16Must also select I10721.I106259-99-0 Stealth Comfort Plus Headrest - 10"W365.16Must also select I10721.I106261-99-0 Stealth Comfort Plus Headrest - 14"W365.16Must also select I10721.I10721 Adj Stealth Headrest Hardware - Each (TWB480)246.84Please select the headrest post length below:I106314-99-0 Standard length (10"): _____ Short length (6"): _____Stealth Swng Away Egg Sw for Comfort Plus Headrest562.02Includes Black Egg Switch and Stealth Comfort Plus Swing Away Hardware (CPS9-R).Please indicate if you want switch mounted on left or right side of headrest:I106316-99-0 Mount Switch on Left: _____Mount Switch on Right: _____Stealth Swing Away Tash Micro Lite for Cmfrt Plus645.15Includes Tash Micro Lite Switch and Stealth Comfort Plus Swing Away Hardware (CPR9-R).Please indicate if you want switch mounted on left or right side of headrest:I10809 Mount Switch on Left: _____Mount Switch on Right: _____Stealth Swing Away Facial Supprt Hdw for Cmfrt Plus331.50Must also select support pad (I10813, I10814, I10815). Please indicate if you want it mountedon left or right side of headrest:Mount Hardware on Left: _____ Mount Hardware on Right: _____I106284-99-0 Stealth #900 Support Pad (4.5" x 2") - Cmfrt Plus129.54I106221-99-0 Stealth 4" x 6" Lateral Spprts, Original Hdwr, HD392.70Must also select I10723. Kit contains thin, Stealth hardware with swing away brackets andtwo height adjustment rails. The rails are bolted to the backrest to provide mounts for thelateral hardware. PLEASE NOTE: The spacing between the armrests must be at least 1"wider than the backrest width when ordering these laterals.I10723 Adj Removable Stealth Lateral Hardware (Pair)512.04Alternative Drive SystemsALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:Part Number DescriptionMSRP - CAI10751 Mini-Joystick for Omni / IOM (9-pin connector)2,641.80Operating Force = 13 g Neutral to Full Deflection = 5mmI103893-99-0 Compact Joystick for Omni / IOM (9-pin connector)1,289.28Operating Force = 220 g Neutral to Full Deflection = 28mm Joystick includes two 3.5mmmono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) FoamBall Knob.I103894-99-0 Compact Joystick LITE for Omni / IOM (9-pin conn)1,474.92Operating Force = 50 g Neutral to Full Deflection = 17mm Joystick includes two 3.5mmmono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) FoamBall Knob.ALT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:Part Number DescriptionMSRP - CAADP $381.48 CodeADP $365.16 CodeADP $2,641.80 CodeADP CodeRev 2013-4 11/4/2013Page 11 of 16

M300 Corpus HDAlternative Drive SystemsCANADIAN MSRP PRICE LISTALT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:Part Number DescriptionMSRP - CANOTE:Please see the PERMOfix Mounting Solutions, within the Alt Drive Accessories section, forI104690-99-0 additional mounting options.Alt. JS Adjustable Mount Kit - Armrest238.68I104695-99-0 Mount in front of Left Arm: _____ Mount in front of Right Arm: _____Alt. JS Adjustable Mount Kit - Midline760.92Mount on Left Arm: _____Mount on Right Arm: _____I104143-99-0 Alt. JS Adjustable Mount Kit - Chin Boom811.92Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom chargeI10752 may be applied if ordering lower backrest heights.Alt. JS Adjustable Mount Kit - Haims Harness, Lrg579.36For neck width up to 19cm.I10753 Alt. JS Adjustable Mount Kit - Haims Harness, Sml579.36For neck width up to 14cm.I10754 Alt. JS Adjustable Mount Kit - Haims Harness, Peds579.36For neck width up to 10cm.I10068 Alt. JS Adj. Mount Kit - Power SwingAway Chin Boom4,409.46Includes power swing away mount off the backrest with adjustable mounting hardware.I10797 Custom charge may be applied if ordering lower backrest heights.Stealth Sw Away Chin Boom for Comfort Plus Headrest533.46Includes Stealth Comfort Plus Swing Away Hardware, 18" boom and bracket for attaching aMini Joystick or Compact Joystick. Please indicate which bracket to include and if you wantboom mounted on left or right side of headrest:Mini Joystick Bracket: _____ Compact Joystick Bracket: _____Mount Boom on Left: _____ Mount Boom on Right: _____ALT PROPORTIONAL JOYSTICK ACCESSORIES:Part Number DescriptionMSRP - CAI104904-99-0 Dual Switches for Compact Joystick - Fixed Mount240.72Includes two pushbutton switches mounted on rigid Switches can be used for Mode & On/Off.Switch operation force = 130 gMount at front of Joystick: _____ Mount at rear of Joystick: _____Mount at left of Joystick: _____ Mount at right of Joystick: _____I104641-99-0 Dual Switches for Compact Joystick - Gooseneck Mnt436.56Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches arepositioned on Left and Right sides of Compact Joystick. Switches can be used for Mode &On/Off. Switch operation force = 130 gTOTAL CONTROL HEAD ARRAY SYSTEM:Part Number DescriptionMSRP - CAI10966 Permobil Head Array - 3-Switch System4,778.70Features an occipital pad sensor and two adjustable arms configured with sensors, switchesor pads. Each arm must be specified in the following sections to complete 3-Switch System.Additional arms and sensors can be added to create a 5-Switch system. ESP recommended.**Choose Omni Control Module (3-Sw/5-Sw) or R-net Input Module (5-Sw only) separately.CHOOSE OCCIPITAL PAD SIZE (REQUIRED)I105920-99-0 Small Occipital Pad for Head Array - 4.25"W x 3"HNo ChargeI105921-99-0 Large Occipital Pad for Head Array - 6"W x 4"HNo Charge.CHOOSE OCCIPITAL PAD MOUNT (REQUIRED):I10847Fixed Mount for Occipital Pad - Head ArrayNo ChargeI105936-99-0 Adj. Swivel Mount for Head Array Occipital Pad428.40Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.CHOOSE BACKREST MOUNTING HARDWARE (REQUIRED):ADP CodeADP $240.72 CodeADP $4,778.70 CodeRev 2013-4 11/4/2013Page 12 of 16

M300 Corpus HDAlternative Drive SystemsCANADIAN MSRP PRICE LISTTOTAL CONTROL HEAD ARRAY SYSTEM:Part Number DescriptionMSRP - CAI105927-99-0 Stealth TWB480 Backrest Mounting Hdwr with Links265.20Please select the length of the vertical stem below:Standard length (10"): _____ Short length (6"): _____I105941-99-0 Stealth TWB480 Backrest Mtng Hdwr with Flipback438.60I105925-99-0 Stealth HMO475 Backr Mtng Hdwr w 17mm Ball224.40I106319-99-0 Stealth TWB480 Backrest Mnt Hdwr w SubOcptl Mount477.36I106282-99-0 Stealth 600 SubOccipital Pad - 8.5"W x 2.75"H96.90.CHOOSE LEFT ARM PACKAGE (REQUIRED):I10859Add Left Lateral Arm w Proximity SensorNo ChargeChoose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______I10860Upper Attachment: ______ Lower Attachment: ______Add Left Lateral Arm w Egg SwitchNo ChargeChoose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______ADP $265.20 CodeI10972I10973CHOOSE RIGHT ARM PACKAGE (REQUIRED):Add Right Lateral Arm w Proximity SensorChoose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______Add Right Lateral Arm w Egg SwitchChoose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______No ChargeNo ChargeSELECT LEFT ARM PACKAGE (OPTIONAL)I10976 Add Left Lateral Arm w Proximity Sensor617.10Choose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______I10977 Add Left Lateral Arm w Egg Switch499.80Choose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______I10978 Add Left Lateral Arm w Pad (No Sensor or Switch)408.00Choose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______SELECT RIGHT ARM PACKAGE (OPTIONAL):I10979 Add Right Lateral Arm w Proximity Sensor617.10Choose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______I10980 Add Right Lateral Arm w Egg Switch499.80Choose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______I10981 Add Right Lateral Arm w Pad (No Sensor or Switch)408.00Choose Lateral Arm Adjustment Range and Attachment Position:Short (5.5" - 8"): ______ Long (9" - 13.5"): ______Upper Attachment: ______ Lower Attachment: ______SIP & PUFF SYSTEMS:Part Number DescriptionMSRP - CAPage 13 of 16Rev 2013-4 11/4/2013ADP $1,549.38 Code

M300 Corpus HDCANADIAN MSRP PRICE LISTAlternative Drive SystemsSIP & PUFF SYSTEMS:Part Number DescriptionMSRP - CA ADP $1,549.38 CodeI10573 Sip & Puff System for Omni1,549.38WEX5Requires Omni Control Module. Cannot use this part with an Input Module. Includes breathI10574 tube kit.Sip & Puff System with Fiber Optic Opti-Stop2,062.44WEX5Requires Omni Control Module. Cannot use this part with an Input Module. Includes breathI10762 tube kit.Adjustable Mounting Hrdw - Sip & Puff240.72Required when selecting PN I10573 or I10574.ALTERNATIVE PROPORTIONAL CONTROL SYSTEMS:Part Number DescriptionMSRP - CAI10763 VIC Proportional Finger Control for Omni / IOM2,750.94The VIC CCD translates small finger movements into proportional driving commands.I10764 VIC Adjustable Mount Kit - Armrest240.72I10765 Mount in front of Left Arm: _____ Mount in front of Right Arm: _____VIC Adjustable Mount Kit - Midline760.92Mount on Left Arm: _____Mount on Right Arm: _____I10317 Proportional Tablet Control for Omni / IOM4,825.62The Tablet Control is a unique drive input which enables a user to control a power wheelchairin a very similar manner to a mouse being controlled by a touchpad on a laptop computer.The dimensions of the Tablet Control Pad are: 30cm Wide x 24cm Long x 4cm Thick Kit alsoI10767 includes: Buddy Button Switch, and Tablet Control Mounting Bracket.Proportional Foot Control2,720.34I10766 Mount on Left: _____Mount on Right: _____Adjustable Mounting Hrdw - Foot Control240.72Required when selecting PN I10767.I10638 RIM Control - SwitchIT for Omni5,121.42Requires Omni Control Module. Cannot use this part with an Input Module.I10770 Adjustable/Removable Hardware - RIM Control240.72Required when selecting PN I10638.Alt Drive Systems SetupCHOOSE OMNI OR INPUT MODULE (REQUIRED):Part Number DescriptionMSRP - CAID51154IR Omni Control Module for R-net w/ Infrared2,159.34Mount in front of Left Arm: _____ Mount in front of Right Arm: _____ Please specifywhich type of alternative drive input you will be using if not ordering the input device fromI10577 Permobil. Input Device: ___________________________Adjustable Swing-Away Hardware - Omni115.26Required when selecting Part Number ID51154IR.I10581 Input Module (IOM) for R-net Control System1,523.88This device allows a proportional or switched drive input to be connected to an R-net ControlSystem without the use of an Omni. It must be ordered in conjunction with an R-net RemoteJoystick. It does NOT support any of the following input devices: Sip-n-Puff, 3-Switch HeadArray or RIM control.CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX:Part Number DescriptionI10080Mount Seat Control Switchbox on BackrestI10079Mount Seat Control Switchbox on LeftI10078Mount Seat Control Switchbox on RightAlt Drive AccessoriesPERMOFIX MOUNTING SOLUTIONS:Part Number DescriptionMSRP - CANo ChargeNo ChargeNo ChargeMSRP - CAADP $2,750.94 CodeADP $2,159.34 CodeADP CodeADP $269.50 CodeRev 2013-4 11/4/2013Page 14 of 16

M300 Corpus HDAlt Drive AccessoriesCANADIAN MSRP PRICE LISTPERMOFIX MOUNTING SOLUTIONS:Part Number DescriptionMSRP - CAI106655-99-0 PERMOfix UniTrack Fixed Mount Kit269.50Includes two base joints, two 4" rods and one 8" rod.I106656-99-0 PERMOfix UniTrack Removable Mount Kit473.00Includes quick release mount and thigh support hardware, two base joints and three differentlength rods.I106658-99-0 PERMOfix UniTrack Fixed Omni Mount Kit506.00Used to mount Omni to UniTrack rail under armrest or on the seat frame. Includes Omnimounting module, four additional modules, two 8" rods and one 4" rod.PERMOFIX SWITCH ASSEMBLIES:Part Number DescriptionMSRP - CAI105907-99-0 Proximity Sensor + Swivel Assm - Not Mounted351.90Swivel assembly allows sensor to be mounted with PERMOfix or directly to lateral arm ofTotal Control Head Array. Since Proximity Sensors require power, they CANNOT be used asOn/Off switches.I105919-99-0 Egg Switch + Swivel Mount Assm - Not Mounted234.60Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm ofTotal Control Head Array.I105912-99-0 Solid Lateral Pad+Swivel Joint - Not Mounted142.80Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of TotalControl Head Array.I106675-99-0 Oval Plate + Swivel Assm - No Switch - Not Mounted123.00Blank plate provides mounting option for Micro Lite, Buddy Button or other switch options.Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of TotalControl Head Array.OPTIONAL ITEMS:Part Number DescriptionMSRP - CAIMICROSWITCH Microlite Switch Qty: _____155.04IBUDDYBUTTON Buddy Button Qty: _____116.28I5808 Mini Cup Switch Qty: _____113.22IZTS-P Proximity Switch Qty: _____540.60IMINIJOY5SW Mini Joystick 5 Switch OC919.02I10771 Touch Contact with CR2032 Battery Qty: _____260.10I10772 Dome Switch, Backrest Mnt w Gooseneck Qty: _____481.44Mount on Left: _____ Mount on Right: _____Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrestheights. Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45°swivel adjustment, one 150mm rod, one 200mm rod and one 225mm gooseneck switch with1.2m cable and mounting clamp.I10846 Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____724.20Mount on Left: _____ Mount on Right: _____w 90° Swing-Away Function. Mounts at top of back. Custom charge applies if ordered withshort back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45°swivel adjustment, two 6" rods, one 90° Swing-Away joint, one 9" gooseneck switch w 50"cable and mounting clamp.I105935-99-0 3.5mm Ext. Cable for Sensor/Switch, 0.3m Long32.64I105931-99-0 3.5mm Ext. Cable for Sensor/Switch, 1m Long36.72I105932-99-0 3.5mm Ext. Cable for Sensor/Switch, 2m Long40.80I105933-99-0 3.5mm Ext. Cable for Sensor/Switch, 3m Long44.88I105934-99-0 3.5mm Y-splitter Cable for Sensor/Switch36.72Allows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.ADP $269.50 CodeADP $351.90 CodeADP $155.04 CodeRev 2013-4 11/4/2013Page 15 of 16

Notes & Additional Instructions:Chair Order Policy:You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at 1-800-736-0925. The order cannotbe processed without the following:-A client name or code, the client’s measurements, the client’s weight-The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, LTD. is notresponsible for configuration or size discrepancies resulting from customer errors on the order form.-Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully.-Once the order is shipped, any changes are subject to the returns policy and may be prohibited.Order Acknowledgement:I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for thepurchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete andaccurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policyand may carry additional charges.Signed:Printed Name:Title:Date:NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Anyparts ordered for service or future alterations will carry different pricing and warranty. MID PROFILE® Cushion is a registered trademark of the The ROHOGroup. The ADP codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does notensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer.Rev 2013-4 11/4/2013Page 16 of 16