Please fill in the details below:

Mr Mrs Miss Ms
Your Name:
Address:
Postcode:
Telephone:
User Weight:

Disability:
Does the scooter / equipment need to be dismantled on a regular basis? (Please tick box if answer is yes.)

Maximum distance to be covered by scooter on a
single battery charge?
0-10 miles 10-20 miles 20-40 miles

Will the scooter be for use on public roads?
(Please tick box if answer is yes.)

Any other questions?
Any other equipment you require information about?