One Month Funded Trial AgreementOne Month Funded Trial Agreement • November 26th, 2014
☐ I-13 Please Select MountTable Top Floor Stand ☐ I-16 Please Select MountTable Top Floor Stand ☐☐ ☐☐ ☐ ☐ I-110 SC Tablet ☐☐☐☐☐ Keyguards TD Snap 2x2 TD Snap 3x3 TD Snap 4x4 TD Snap 5x5 TD Snap 6x6 ☐☐☐☐☐ C5 4x3 C5 6x4 C5 7x5 C5 8x5 C5 8x6 ☐☐☐ 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:
