M300 PS. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information

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1 * Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Address: Client Information Permobil recommends that the client is evaluated by a certified 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: Three column pricing on order/quote: Display HCPCS Codes on order/quote: Please send order/quote to fax#: (800) to: sales@permobil.com Permobil Inc. 300 Duke Dr. Lebanon, TN Tel: (800) Fax: (800) Prices effective April 8, 2013

2 Chair Model and Colors CHOOSE BASE: I10643 M300 Base PS - M300 NPO 6, K0848 Price Includes: M300 Power Base Set Up For No Power Seat Functions, Shock Absorbing Suspension System, Tie-Down Hardware For Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below. 6.0mph, Weight Capacity = 300lbs, STFH = 17.5". I M300 Base PS - M300 SPO 6, K0856 Price Includes: M300 Power Base Set Up For One Power Seat Function, Shock Absorbing Suspension System, Tie-Down Hardware for Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below. 6.0mph, Weight Capacity = 300lbs, STFH = 17.5". I MPH HIGH SPEED UPGRADE PACKAGE - M300 2, Price Includes 7.5mph High Speed Motor Package. Available with R-net Electronics only. CHOOSE DRIVE TIRES: I Tri-Spoke Split Rim w/ Flat Free Drive Tire 3x8" No Charge I Tri-Spoke Split Rim w/ Pneumatic Tires - 3x8" No Charge OPTIONAL DRIVE TIRES: I10782 Tri-Spoke Split Rim w/ Snow Tire Pneumatic 3x8" Snow tires are designed for use in cold weather conditions. The nylon compound in these tires 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 ordered along with standard drive wheels. CHOOSE SHROUD COLOR: I M300 Shroud - Onyx Black No Charge I M300 Shroud - Platinum Silver No Charge I M300 Shroud - Sublime Green No Charge I M300 Shroud - Cobalt Blue No Charge I M300 Shroud - Phantom Grey No Charge I M300 Shroud - Pop Star Pink No Charge I M300 Shroud - Purple Rain No Charge I M300 Shroud - Volcano Red No Charge I M300 Shroud - Digital Army Camo (UCP) Hydrographic processing used to apply design. Includes no-gloss clear coat. I M300 Shroud - MultiCam Camo Hydrographic processing used to apply design. Includes no-gloss clear coat. I M300 Shroud - Realtree AP Camo Hydrographic processing used to apply design. Includes no-gloss clear coat. CHOOSE HUBCAP COLOR: Match Hub Cap Color to Shroud: Note: Hub caps will be matched to shroud color/decoration if no selection is made. Matched hub caps carry the prices listed below. I10871 Solid Color Hub Caps - Pair No Charge Platinum 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: I10872 Decorated Hub Caps - Pair Digital Army Camo: MultiCam Camo: RealTree AP Camo: Base Options MUST CHOOSE EITHER SEAT ELEVATOR OR FIXED SEAT TUBE: Page 2 of 13

3 Base Options MUST CHOOSE EITHER SEAT ELEVATOR OR FIXED SEAT TUBE: I Seat Tube Fixed No Charge I Power Adjustable Seat Height - 8" Travel 2, E2300 MUST CHOOSE BATTERIES: IM24 SLD G FT Batteries, Grp 24 (72Ah) Sealed LA/Gel, Installed E2363 IM34 SLDG Batteries, Grp 34 (60Ah) Sealed LA/Gel, Installed E2359 I10828 Seat Stabilizer Option - PS Seat Seat Stabilizer cannot be selected if PS seating system is ordered WITHOUT Tilt. I Enhanced Steering Perform Unit (ESP), R-net 1, K0108 Recommended item with switched drive inputs for improved tracking. I LED Light Kit for M300 / M400 w/ R-net Electronics 1, ID51113 Programming Key for R-net - Permobil Version I Stealth BPAP Vent Tray - MWD Base K0108 Designed for BPAP systems, the tray has a 12"W x 7"D surface that can support up to 40 lbs. A 1" lip and adjustable strap help secure contents. The tray mounts to the rear tie-down loops, is tapered to fit between the rear swing arms and extends 1" beyond the trailing casters. Permolock I Permolock C3 Locking Base Kit 1, Kit Includes: Permolock C3 Locking Base, Owner's Manual, Manual Release Handle, and Vehicle Mounted Release Button. Does NOT include Dual Locking Pin Kit (I10608). Locking Base must be installed by a NMEDA Dealer. Please provide the NMEDA Dealer and Address where the locking Base will ship to: NAME: ADDR: I10608 Permolock C3 Dual Locking Pin Kit- C/K300, M-series This kit includes two spring loaded pins that will be mounted underneath the base of the wheelchair. These pins are spring loaded so they push into the wheelchair base when an obstacle is encountered. The kit also includes spacers that may be used if the Permolock C3 Base is being mounted in a vehicle with a sloped floor. The spacers are only needed for a C300 or K300. Joystick Options CHOOSE JOYSTICK TYPE: PLEASE NOTE: For additional input devices, refer to Alterative Drive Systems Section. I R-net LED Remote Joystick Module No Charge Standard Joystick Module. This Joystick does NOT have an LCD Display and does NOT contain mono jacks. Limited to five profiles with this Joystick Module. ID51185 R-net Remote Color JS w/ Mono Jacks, No Lights ID51188 R-net Remote Color JS w/ Toggle Switches, No Lghts ID51153 R-net Remote Color JS w/ Mono Jacks, Lights ID51149 R-net Remote Color JS w/ Toggle Switches, Lights ID51190 R-net Remote Color JS w/ Spd Pot/Toggle, Lights I R-net Remote Color JS w/ Lights, Heavy Duty Gimble 1, Heavy-Duty modification enables gimble to hold up to extreme operating forces. Reinforced housing is attached to a standard Color LCD R-net Joystick. 3" long joystick knob has 3/4" diameter. Not compatible with alternative joystick handles. I Compact Advanced Joystick for R-net E2373 Compact sized joystick that does not contain an LCD Display. Must order expandable controller (PN: I10411) with this part. Contains two mono jacks for mode & 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 Advanced Page 3 of 13

4 Joystick Options CHOOSE JOYSTICK HANDLE TYPE: I10045 Cone Shaped Joystick Knob - Standard No Charge I Chin Cup For Joystick Knob E2324 I "T" Handle For Joystick Knob E2323 I "Large Ball" For Joystick Knob E2323 I "Softball" For Joystick Knob E2323 I "Mushroom" For Joystick Knob E2323 I "Stick" For Joystick Knob E2323 I " Black Foam Ball For Joystick Knob E2323 IPC101B Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft E2323 IPC102B Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft E2323 IPC107B Bodypoint J/S Handle Dome Shaped, Rubber E2323 CHOOSE JOYSTICK MOUNT: I10412 Joystick Mount Right - Fixed, R-net Only No Charge I10413 Joystick Mount Left - Fixed, R-net Only No Charge I Joystick Mount Right - Swing Away, R-net & VR E1028 I Joystick Mount Left - Swing Away, R-net & VR E1028 I Retractable Joystick Mnt Right - R-net, VR E1028 I Retractable Joystick Mnt Left - R-net, VR E1028 I Mount Standard Joystick Backrest, PS,VS,C300 TILT Standard R-net Joystick is mounted to backrest. Can be chosen instead of PN ID Not available with VR2 Controllers. Mount on Left: Mount on Right: I Midline Control Mount - Pilot+ & R-net E1028 Mount Midline on Left Armrest: Mount Midline on Right Armrest: I10793 Stealth Gatlin Mid Line Mount - 8 Position E1028 Features eight locking positions each 45 apart. Adjustments are made by pulling out on mounting arm and rotating to desired angle. 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: I10794 Stealth Gatlin Mid Line Mount - 2 Position E1028 Designed for easy swing away. Mount can be set to swing from horizontal to 95 or from horizontal 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: I10803 Stealth Gatlin Bracket for R-net/Compact JS Adv E1028 I10804 Stealth Gatlin Bracket for Compact Joystick E1028 I10805 Stealth Gatlin Bracket for Mini-Joystick E1028 I10806 Stealth Gatlin Swivel Bracket for Omni E1028 I10842 PERMOFix Joint for Gatlin ( a) E1028 Includes a shim washer that allows the PermoFix joint to be mounted on the 1/2" Stealth Gatlin arm. Provides an adjustable mount for a Mini Joystick or Compact Joystick. I10411 Expandable Controller - R-net E2377 This item is required when ordering power tilt, power recline, and power elevating legrests together OR when ordering an Alternative Drive Control. I10513 Harness for Expandable Controller E2313 Must be ordered with any Expandable Controller (I10411 or I10450). ID50882 Attendant Control for R-net Control System Only 1, E2331 Not available with VR2 Controllers. Page 4 of 13

5 Joystick Options I R-net BT Mouse Module w/ Two Switch Adapters The R-net BT Mouse Module enables mouse control through any R-net Input Device (ex. Standard JSM, Mini-JS w/ Omni, etc). It can only operate the mouse on a computer. It CANNOT be paired to work with other Bluetooth devices such as cell phones, wireless headsets, etc. This kit includes: a R-net BT Mouse Module, a 1.5m R-net Bus Cable, two mono jack cables for L/R click (switches not included), & a USB BT Adapter for the user's computer. Note: The BT Adapter may not work with all computers. I10582 Output Module (IOM) for R-net Control System 1, E2351,K0108 This allows a user to control an external device (ex: Communication Device, ECU, Door Opener, etc.) through the drive input (JSM, Head Array, etc.). One output module is required for each separate external device to be controlled. Up to three output modules can be installed on one wheelchair. Seating System I PS Seating System - No Tilt No Charge I10724 PS Seating System with 50 CG Power Tilt 5, E1002 Weight Limit 300lbs. Seating System Options CHOOSE SEAT FUNCTION CONTROL TYPE: I10418 Single Seat Function Control Switch for R-net No Charge Please choose either Push Buttons or Toggle Switches below. I10419 Single Seat Function Control Kit for R-net 1, E2310 For operation of a single seat function through the wheelchair electronics via the drive control and/or ICS Switchbox. Order with R-net Controller or remote joystick options. Please indicate below if you want push buttons or toggles on the ICS Switchbox. I10585 Multiple Seat Function Control Kit for R-net 3, E2311 MUST be selected if ordering two or more seat functions. This device is used to operate two or more seat functions through the wheelchair electronics via the drive control and/or ICS switch box. Order with R-net electronics or remote joystick options. Please indicate below if you want push buttons or toggles on the ICS Switchbox. CHOOSE PUSH BUTTONS OR TOGGLES: I Push Buttons on ICS Switchbox No Charge I Toggle Switches on ICS Switchbox I Do Not Install ICS Switchbox, Send as Part No Charge CHOOSE MOUNTING POSITION OF ICS SWITCHBOX: I10626 Mount ICS Switchbox onto R-net Joystick Bracket No Charge ICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item is selected, the ICS Switchbox will swing away with the Joystick Module. I Mount ICS Switchbox on Backrest Mount on Left: Mount on Right: I Mount ICS Switchbox on Left No Charge I Mount ICS Switchbox on Right No Charge Page 5 of 13

6 Seating System Options I ICS Alternative Switchbox for R-net Electronics 1, K0108 Not available with VR2 Electronics. Seat function interface box which accommodates up to 8 momentary switches. Provides an additional method to accessing the seat functions. You must still order the Multiple Seat Function Control Kit if ordering this part. 1/8" mini-mono switches not included. Backrest Options I10144 Sling Upholstery Back Support - Standard No Charge Width will be the same as seat width. I10145 Curved Metal Back Support 22" High I10146 Curved Metal Back Support 22" High - No Charge No Charge No charge if ordering tilt. I10454 Omit PS Backrest No Charge Must select when ordering a custom backrest. I10148 Angle Adjustable Back Canes Angle adjustable from 85 to 115 degrees. I10149 Angle Adjustable Back Canes - No Charge No Charge No charge if ordering tilt. Seat Sizing I10150A Seat Width 16" No Charge I10151A Seat Width 18" No Charge I10219A Seat Width 20" No Charge I10220A Seat Width 22" No Charge I10156 Seat Depth 16" No Charge I10157 Seat Depth 17" No Charge I10158 Seat Depth 18" No Charge I10159 Seat Depth 19" No Charge I10221 Seat Depth 20" No Charge I10222 Seat Depth 21" No Charge I10223 Seat Depth 22" No Charge Armrest Options I10163 Height Adjustable Armrest Assembly PS E0973 Adjustable in height, with a flip-back design. I10230 Height Adjustable Armrest Assembly PS - No Charge No Charge Adjustable in height, with a flip-back design. No charge if ordering power tilt. I10290 PS Armrest Pads "L x 2"W (Pair) No Charge I10291 PS Armrest Pads - 14"L x 2"W (Pair) No Charge I10292 Waterfall Armrest Pad for PS "L x 3"W (Pair) I10168 Omit Armrest Pads No Charge Page 6 of 13

7 Armrest Options I10166 Corpus Armrest Pad Adapter Brackets Must be picked if ordering Corpus armrest pads. I10208 Corpus Armrest Pad 4"x10" Left Leatherette I10209 Corpus Armrest Pad 4"x12" Left Leatherette I10210 Corpus Armrest Pad 4"x14" Left Leatherette I10211 Corpus Armrest Pad 4"x16" Left Leatherette I10212 Corpus Armrest Pad 4"x10" Right Leatherette I10213 Corpus Armrest Pad 4"x12" Right Leatherette I10214 Corpus Armrest Pad 4"x14" Right Leatherette I10215 Corpus Armrest Pad 4"x16" Right Leatherette I10169 Armrest Side Support Right Inner Will limit the armrest from flipping back. For Corpus Armrest Pads only. I10170 Armrest Side Support Left Inner Will limit the armrests from flipping back. For Corpus Armrest Pads only. I Armrest Side Support Right Outer For Corpus Armrest Pads only. I Armrest Side Support Left Outer For Corpus Armrest Pads only. Legrest Options I Degree Swing Away Legrests (Pair) I Degree Swing Away Legrests (Pair) No Charge No charge if ordering Power Tilt. I10625 Aeron Legrest Assembly for PS Seat - Narrow Legrest Hanger with Manual Adjustment Legrest Elevation. Price includes 6"W x 9"D Corpus Style, Angle Adjustable, Two Piece Footplates. Range of adjustment from the seat pan to the top of the footplate is: 12-17" (with calf pads) and " (without calf pads). I10173 Footplates (Pair), Standard Small No Charge I10174 Footplates (Pair), Standard Large No Charge Not available with 16" seat width. I10175 Small Footplates, Multi - Axis Adjustable, Aluminum K0108 I10176 Large Footplates, Multi - Axis Adjustable, Aluminum K0108 Cannot be ordered with 16" or 18" seat widths. I UT Calf Support Kit (B) w Mesh Cover & Adj Hardware No Charge 3.5"W x 4.5"T Pad. Recommended pad to be used with lower leg lengths of 12" or less. Bracket designed for use with Aeron Center Mount Legrest Assembly. Cannot be ordered with Swing Away Legs (I10586 & I10587). I UT Calf Support Kit (J) w Mesh Cover & Adj Hardware No Charge 5"W x 6.5"T Pad. Bracket designed for use with Aeron Center Mount Legrest Assembly. Cannot be ordered with Swing Away Legs (I10586 & I10587). I10177 Heel Loops E0951 Not available with Aeron Legrest Assembly. (I10316). I10197 Calf Supports Leatherette No Charge Not available with lower leg lengths of 10" or less. Accessories Page 7 of 13

8 Accessories I10401 Bodypoint Non-Padded Hip Belt, PS - Medium No Charge I10406 Bodypoint Padded Hip Belt PS (C300) - Medium E0978 I10403 Bodypoint Non-Padded Hip Belt, PS - Large E0978 I10409 Bodypoint Padded Hip Belt PS - Large E0978 I10199 Headrest-Removable Leatherette E0955 Must also select PN I I UT Ergo Headrest w/ Black Fabric Cover E0955 Must also select PN I I10180 Universal Headrest Adapter K0108 Will be sent as part if ordering sling back upholstery. I10552 Adj Removable - Headrest Hardware (1 Each) E1028 I10783 Hand Heater Kit with Buddy Button Kit includes Hand Heater (2"H x 1.5"W x 2.75"D), Buddy Button, Power Cable with XLR Plug and PERMOfix Mounting Adapter. Heater has three temp/fan speed settings. For best results, a hand cone (I10784 or I10785) is recommended to trap heat around the user's hand(s). To ensure best positioning for the user, heater will NOT be mounted when chair is received. I10784 One-Hand Cone Kit with PERMOfix Mounting Set Clear plastic dome (5.5"W x 13.5"L x 8"H) with forearm opening at one end. Kit includes PERMOfix mounting hardware to attach cone to end of armrest. To ensure best positioning for the user, cone will NOT be mounted when wheelchair is received. I10785 Two-Hand Cone Kit with Mounting Pins Clear plastic triangular dome (15"W x 12.5"L x 8"H) with two forearm openings. Use with Upper Extremity Support is recommended. Kit includes four pins to secure cone to tray surface. Pins remove without tools for easy transfers. To ensure the best positioning for the user, cone will NOT be mounted. I Self-Leveling Cup Holder I Medical Necessities Bag Hooks I Medical Necessities Bag CII,VS,PS,C3G,HD Includes hardware to attach bag to backrest. I Bodypoint Monoflex Large Chest Support Belt Kit E "L x 4.5"W Pad Size. Item will be shipped as parts. I Bodypoint Monoflex Medium Chest Support Belt Kit E "L x 4"W Pad Size. Item will be shipped as parts. I Bodypoint Monoflex X-Lrge Chest Support Belt Kit E "L x 5"W Pad Size. Item will be shipped as parts. I Upper Extremity Support Small, Angle Adjustable E0950 Must also select PN I I10556 Adj Removable - Tray Hardware (1 Each) E1028 I Oxygen Holder for PS or Corpus Seat E2208 Cannot be ordered with a Corpus Tubular Backrest. (I10111 or I10112). Custom charge may be applied if ordering in combination with accessories such as medical necessities bags, attendant controls, push handles, back pack clips, etc. This item is mounted to the Ergonomic Backrest. Customization may be required if ordering on a Street. I Crutch Holder for PS or Corpus Seat E2207 Cannot be ordered with a Corpus Tubular Backrest. (I10111 or I10112). Accessories such as medical necessities bags and push handles may need to be sent as parts if ordering a crutch holder. This item is mounted to the ergonomic backrest. Customization may be required if ordering on a Street. Stealth Accessories I10869 Stealth Ultra Headrest E0955 Includes Stealth Occipital pad (500 series), Sub Occipital pad (600 series) and Flip Down Headrest Mount (TWB480-QFDM). Select Stealth headrests accessories and alternative drive mounts to complete headrest assembly. Page 8 of 13

9 Stealth Accessories I10800 Stealth Swing Away Egg Switch for Ultra Headrest E1028 Includes Black Egg Switch and Stealth Ultra Swing Away Hardware (SUS9-R). Please indicate if you want switch mounted on left or right side of headrest: Mount Switch on Left: Mount Switch on Right: I10893 Stealth Swing Away Tash Micro Lite for Ultra E1028 Includes Tash Micro Lite Switch and Stealth Ultra Swing Away Hardware (SUS9-R). Please indicate if you want switch mounted on left or right side of headrest: Mount Switch on Left: Mount Switch on Right: I10801 Stealth Swing Away Facial Supprt Hdw for Ultra E1028 Must also select support pad (I10810, I10811, I10812). Please indicate if you want it mounted on left or right side of headrest: Mount Hardware on Left: Mount Hardware on Right: I10810 Stealth #900 Support Pad (4.5" x 2") - Ultra K0108 I10811 Stealth #910 Support Pad (3" x 2") - Ultra K0108 I10812 Stealth #920 Support Pad (6.4" x 2") - Ultra K0108 I10718 Stealth Comfort Plus Headrest - 8"W E0955 Must also select I I10719 Stealth Comfort Plus Headrest - 10"W E0955 Must also select I I10720 Stealth Comfort Plus Headrest - 14"W E0955 Must also select I I10721 Adj Stealth Headrest Hardware - Each (TWB480) E1028 Please select headrest post length below: Standard length (10"): Short length (6"): I10736 Stealth Swng Away Egg Sw for Comfort Plus Headrest E1028 Includes 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: Mount Switch on Left: Mount Switch on Right: I10894 Stealth Swing Away Tash Micro Lite for Cmfrt Plus E1028 Includes 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: Mount Switch on Left: Mount Switch on Right: I10809 Stealth Swing Away Facial Supprt Hdw for Cmfrt Plus E1028 Must also select support pad (I10813, I10814, I10815). Please indicate if you want it mounted on left or right side of headrest: Mount Hardware on Left: Mount Hardware on Right: I10813 Stealth #900 Support Pad (4.5" x 2") - Cmfrt Plus K0108 I10814 Stealth #910 Support Pad (3" x 2") - Cmfrt Plus K0108 I10815 Stealth #920 Support Pad (6.4" x 2") - Cmfrt Plus K0108 Alternative Drive Systems ALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS: I10751 Mini-Joystick for Omni / IOM (9-pin connector) 2, E2312 Operating Force = 0.5 oz (13 g) Neutral to Full Deflection = 0.2" (5mm) I Compact Joystick for Omni / IOM (9-pin connector) 1, E2373 Operating Force = 7.8 oz (220 g) Neutral to Full Deflection = 1.1" (28mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob. I Compact Joystick LITE for Omni / IOM (9-pin conn) 1, E2373 Operating Force = 1.8 oz (50 g) Neutral to Full Deflection = 0.7" (17mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob. CHOOSE MOUNTING HARDWARE: I Alt. JS Adjustable Mount Kit - Armrest E1028 Mount in front of Left Arm: Mount in front of Right Arm: Page 9 of 13

10 Alternative Drive Systems CHOOSE MOUNTING HARDWARE: I Alt. JS Adjustable Mount Kit - Midline E1028 Mount on Left Arm: Mount on Right Arm: I Alt. JS Adjustable Mount Kit - Chin Boom E1028 Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge may be applied if ordering lower backrest heights. I10752 Alt. JS Adjustable Mount Kit - Haims Harness, Lrg E1028 For neck width up to 7½". I10753 Alt. JS Adjustable Mount Kit - Haims Harness, Sml E1028 For neck width up to 5½". I10754 Alt. JS Adjustable Mount Kit - Haims Harness, Peds E1028 For neck width up to 4". I10068 Alt. JS Adj. Mount Kit - Power SwingAway Chin Boom 4, K0108 Includes power swing away mount off the backrest with adjustable mounting hardware. Custom charge may be applied if ordering lower backrest heights. I10795 Stealth Swing Away Chin Boom for Ultra Headrest E1028 Includes Stealth Ultra Swing Away Hardware, 18" boom and bracket for attaching a Mini Joystick or Compact Joystick. Please indicate which bracket to include and if you want boom mounted on left or right side of headrest: Mini Joystick Bracket: Compact Joystick Bracket: Mount Boom on Left: Mount Boom on Right: I10797 Stealth Sw Away Chin Boom for Comfort Plus Headrest E1028 Includes Stealth Comfort Plus Swing Away Hardware, 18" boom and bracket for attaching a Mini Joystick or Compact Joystick. Please indicate which bracket to include and if you want boom mounted on left or right side of headrest: Mini Joystick Bracket: Compact Joystick Bracket: Mount Boom on Left: Mount Boom on Right: I10807 Stealth Gatlin Eclipse Tray with Mini JS Mount E1028 Designed to mount on Stealth Gatlin Mid Line Mounts. Includes bracket for mounting a Mini Joystick under tray. Mini Joystick sold separately. Through hole in tray surface provides joystick access. Please indicate side of tray for hole position: Position Hole on Left: Position Hole on Right: ALT JOYSTICK ACCESSORIES: I Dual Switches for Compact Joystick - Fixed Mount K0108 Includes two pushbutton switches mounted on rigid arms. Switches can be used for Mode & On/Off. Switch operation force = 4.5oz (130 g) Mount at front of Joystick: Mount at rear of Joystick: Mount at left of Joystick: Mount at right of Joystick: I Dual Switches for Compact Joystick -Gooseneck Mount K0108 Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are positioned on Left and Right sides of Compact Joystick. Switches can be used for Mode & On/Off. Switch operation force = 4.5oz (130 g) TOTAL CONTROL HEAD ARRAY SYSTEM: I Permobil Head Array - 3-switch Basic System 4, E2330 Includes Short Adjustable Lateral Arms with Proximity Sensors mounted in Upper Left and Upper Right positions. Short arms can be adjusted from 5.5" to 8" long. ** Complete the Head Array system by choosing pads, hardware and accessories below. ** Choose Omni Control Module (3-sw/5-sw) or R-net Input Module (5-sw only) separately. CHOOSE OCCIPITAL PAD SIZE (REQUIRED): I Small Occipital Pad for Head Array "W x 3"H No Charge I Large Occipital Pad for Head Array - 6"W x 4"H No Charge. CHOOSE OCCIPITAL PAD MOUNT (REQUIRED): I10847 Fixed Mount for Head Array Occipital Pad No Charge Page 10 of 13

11 Alternative Drive Systems TOTAL CONTROL HEAD ARRAY SYSTEM: I Adj. Swivel Mount for Head Array Occipital Pad K0108 Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms. CHOOSE BACKREST MOUNTING HARDWARE (REQUIRED): I Stealth TWB480 Backrest Mounting Hdwr with Links E1028 Please select the length of the vertical stem below: Standard length (10"): Short length (6"): I Stealth TWB480 Backrest Mnt Hdwr with Flipback E1028 I Stealth HMO475 MultiAxis Backrest Mounting Hdwr E1028 I10848 Stealth TWB480 Backrest Mnt Hdwr w SubOcptl Mount E1028 I10855 Stealth 600 SubOccipital Pad - 8.5" W x 2.75" H K0108 Must select when PN I10848 is ordered. SELECT LOWER LEFT ARM PACKAGE (OPTIONAL): I10859 Add Lateral Arm to Lower Left of Head Array E1028 Must also select Sensor, Switch or Solid Pad. Choose Lateral Arm Adjustment Range: Short (5.5" - 8"): Long (9" "): I10861 Add Proximity Sensor to Lower Left Lateral Arm K0108 Since Proximity Sensors require power, they CANNOT be used as On/Off switches. I Add Egg Switch Assm to Lower Left Lateral Arm I Add Solid Pad to Lower Left Lateral Arm K0108. SELECT LOWER RIGHT ARM PACKAGE (OPTIONAL): I10860 Add Lateral Arm to Lower Right of Head Array E1028 Must also select Sensor, Switch or Solid Pad. Choose Lateral Arm Adjustment Range: Short (5.5" - 8"): Long (9" "): I10862 Add Proximity Sensor to Lower Right Lateral Arm K0108 Since Proximity Sensors require power, they CANNOT be used as On/Off switches. I Add Egg Switch Assm to Lower Right Lateral Arm I Add Solid Pad to Lower Right Lateral Arm K0108 HEAD ARRAY ACCESSORIES: I Proximity Sensor + Swivel Assm - Not Mounted K0108 Since Proximity Sensors require power, they CANNOT be used as On/Off switches. I Egg Switch + Swivel Mount Assm - Not Mounted K0108 I Solid Oval Pad + Swivel Assm - Not Mounted K0108 I mm Ext. Cable for Sensor/Switch, 0.3m Long K0108 I mm Ext. Cable for Sensor/Switch, 1m Long K0108 I mm Ext. Cable for Sensor/Switch, 2m Long K0108 I mm Ext. Cable for Sensor/Switch, 3m Long K0108 I mm Y-splitter Cable for Sensor/Switch K0108 Allows two Proximity Sensors/Mechanical Switches to connect to the same direction jack. I10858 PERMOfix Mount Kit for Sensor/Switch on UT Rail K0108 Enables Sensors/Switches with Swivel Assemblies to be mounted to UniTrack Rails. Kit includes one PERMOfix joint with Flat Plate, hardware to mount to UT rail, one PERMOfix joint with 90 swivel adjustment and two 4" rods. SIP & PUFF SYSTEMS: I10573 Sip & Puff System for Omni 1, E2325,E2326 Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tube kit. I10574 Sip & Puff System with Fiber Optic Opti-Stop 2, E2325,E2326 Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tube kit. Page 11 of 13

12 Alternative Drive Systems SIP & PUFF SYSTEMS: I10762 Adjustable Mounting Hrdw - Sip & Puff E1028 Required when selecting PN I10573 or I ALTERNATIVE PROPORTIONAL CONTROL SYSTEMS: I10763 VIC Proportional Finger Control for Omni / IOM 2, E2328 The VIC CCD translates small finger movements into proportional driving commands. I10764 VIC Adjustable Mount Kit - Armrest E1028 Mount in front of Left Arm: Mount in front of Right Arm: I10765 VIC Adjustable Mount Kit - Midline E1028 Mount on Left Arm: Mount on Right Arm: I10317 Proportional Tablet Control for Omni / IOM 4, E2328 The Tablet Control is a unique drive input which enables a user to control a power wheelchair in a very similar manner to a mouse being controlled by a touchpad on a laptop computer. The dimensions of the Tablet Control Pad are: 12"W x 9.5"D x 1.5" Kit also includes: Buddy Button Switch, and Tablet Control Mounting Bracket. I10767 Proportional Foot Control 2, Mount on Left: Mount on Right: I10766 Adjustable Mounting Hrdw - Foot Control E1028 Required when selecting PN I I10638 RIM Control - SwitchIT for Omni 5, E2328 Requires Omni Control Module. Cannot use this part with an Input Module. I10770 Adjustable/Removable Hardware - RIM Control E1028 Required when selecting PN I Alt Drive Systems Setup CHOOSE OMNI OR INPUT MODULE (REQUIRED): ID51154IR Omni Control Module for R-net w/ Infrared 1, Mount in front of Left Arm: Mount in front of Right Arm: Please specify which type of alternative drive input you will be using if not ordering the input device from Permobil. Input Device: I10577 Adjustable Swing-Away Hardware - Omni E1028 Required when selecting Part Number ID51154IR. I10581 Input Module (IOM) for R-net Control System 1, K0108 This device allows a proportional or switched drive input to be connected to an R-net Control System without the use of an Omni. It must be ordered in conjunction with an R-net Remote Joystick. It does NOT support any of the following input devices: Sip-n-Puff, 3-Switch / 4-switch Head Array or RIM control. CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX: I10080 Mount Seat Control Switchbox on Backrest No Charge I10079 Mount Seat Control Switchbox on Left No Charge I10078 Mount Seat Control Switchbox on Right No Charge Alt Drive Accessories IMICROSWITCH Microlite Switch Qty: K0108 IBUDDYBUTTON Buddy Button Qty: K0108 I5808 Mini Cup Switch Qty: K0108 IZTS-P Proximity Switch Qty: K0108 IMINIJOY5SW Mini Joystick 5 Switch OC K0108 I10771 Touch Contact with CR2032 Battery Qty: K0108 Page 12 of 13

13 Alt Drive Accessories I10772 Dome Switch, Backrest Mnt w Gooseneck Qty: K0108 Mount on Left: Mount on Right: Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest heights Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45 swivel adjustment, one 6" rod, one 8" rod and one 9" gooseneck switch with 50" cable and mounting clamp. I10846 Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty: K0108 Mount on Left: Mount on Right: w 90 Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with short 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. Additional Order Instructions: Notes & Comments: Chair Order Policy: You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at The order cannot be 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, Inc. is not responsible 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 the purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and accurate 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 policy and 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. Any parts ordered for service or future alterations will carry different pricing and warranty. MID PROFILE Cushion is a registered trademark of the The ROHO Group. The HCPCS codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer. Page 13 of 13