Alber USA LLC 1005 International Drive Oakdale ORDER Invoice address Company Street City E35 E36 Plus Q U O TAT I O N Customer No. PO No. ST ZIP Standard Optional field Mandatory fields:1) Shipping address (if different from invoice address) 1 Company Street City ST ZIP Type of order Dealer installation *Pending service dept approval* Installation by Alber USA in factory $ 45.00 Order marked for e-fix E35 (260 lbs max.) Battery pack, 6 Ah (216 Wh) Standard for E35 Battery pack, 7.5 Ah (270 Wh) (additional charge) Size of drive wheel 22" 24" **REQUIRED** Wheelchair details Wheelchair manufacturer (ex. Invacare) Model (ex. Myon) Year of construction Equipped with vehicle retention system EZ Lock Tiedown Amputee axle plate **DRUM BRAKES MUST BE REMOVED!** Important hardware Wheelchair mounting bracket *Possible additional fee for brackets dependent on chair contact Alber USA with questions* Anti-tippers with jack-up function *Not compatible with all wheelchairs contact Alber USA with questions* Comments (mounting, delivery, etc.) $ 7,295.00 $ 0.00 $ 300.00 e-fix E36 Plus (350 lbs max.) Battery pack, 7.5 Ah (270 Wh) Standard for E36 Battery pack, 6 Ah (216 Wh) (price reduction) Size of drive wheel 24" **REQUIRED** Seat width (seat tube measured on the outside) Rear seat height $ 7,895.00 $ 0.00 - $ 300.00 inch inch $ 0.00 (pair) $ 400.00 Standard control unit mounting Left (instead of right) Right **REQUIRED** Armrest style Tubular or swing away Desk or full pad style: With transfer loop No user access (if attendant mount) Without transfer loop Alber USA LLC 1005 International Drive Oakdale E35 E36 Plus Control unit accessories Swing away arm Protection bumper Attendant mount (for standard controller) Side: Right Left Style Push handle Stroller handle Joystick option Option special, 40 mm/1.57 inch Option soft, 70 mm/2.76 inch Option T-handle Standard Optional field Mandatory fields: The order cannot be processed without details! $ 495.00 $ 99.00 $ 295.00 Battery accessories Spare battery, 6.0 Ah (216 Wh) Spare battery, 7.5 Ah (270 Wh) Transport bag for spare battery Attachment set for transport bag Spare battery charger 2 $ 950.00 $ 1,250.00 $ 110.50 $ 38.50 $ 435.00 $ 55.00 $ 55.00 $ 178.00 Spoke covers for drive wheels Alber logo, 24" Alber logo, 22" Transparent, 24" Transparent, 22" (pair) $ 252.00 (pair) $ 252.00 (pair) $ 252.00 (pair) $ 252.00 Extension for speed preselection (larger speed dial) Extension for speed preselection $ 76.00 Extension for coupling ring Set for one drive wheel Set for two drive wheels $ 205.50 $ 400.50 Remote interface for external devices and controls Opti-Box (Remote interface) Opti-Box bracket $ 562.00 $ 154.00 Switches (Opti-Box required) External on/off switch Buddy button Speed stop/Speed limit switch (need for standing wheelchairs) $ 203.50 $ 130.00 Intuitive attendant control Intuitive attendant control unit (Push/Brake aid) Opposing push handle Intuitive control mounting hardware Side: Right Left Style: Push handle Stroller handle $ 995.00 $ 115.00 $ 285.00 External charging socket External charger socket incl. clip $ 188.50 Contact Name: Email: Date / / Signature of ordering party As of April, 2017. All prices are subject to the statutory VAT, and include packaging FOB. The General Terms and Conditions of Alber USA LLC shall apply; subject to changes.Online2PDF.com Online2PDF.com