One Month Funded Trial AgreementTrial Agreement • February 2nd, 2022
Contract Type FiledFebruary 2nd, 2022☐☐ I-13 I-16 Please Select MountTable Top Floor Stand ☐ TD Pilot Please Select MountTable Top Floor Stand ☐☐ ☐☐ ☐ ☐ TD I-110 SC Tablet ☐☐☐☐☐ Keyguards TD Snap 2x2 TD Snap 3x3 TD Snap 4x4 TD Snap 5x5 TD Snap 6x6 ☐☐☐ Mount Options Table Top Floor Stand Wheelchair* *Only one mount can be supplied ☐☐ ☐☐ Head Tracking Headmouse TrackerPro Switches Buddy Button Microlight If selecting a Wheelchair Mount, please also select a fastener: ☐ Round Tube ☐ Side Clamp ☐ Channel Nut ☐ Permobil If you are not sure which Chair Fastener is needed, please specify wheel chair make and model: