AADL # W324 ORDER FORM

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1 Page 1 of 6 Effective: July AADL Account Information Account #: Order Date: P.O.# Business Name: Phone: Ship to Address: City: Fax: Province: Postal Code: Contact: 1 FRAME TYPE R Orion II $2,500 Standard Features: A1 Power Tilt MA31 $1,600 Seat Width 18" 2 FRAME FINISH Seat Depth 18" Black C01 No Charge Canes and Stroller Bar Silver C02 No Charge T-Style Height Adjustable Full Length Gel Seat to Floor 18" 3 SEAT WIDTH Rear Wheels 24" 15" Seat Width SW15 No Charge Casters 8" 16" Seat Width SW16 No Charge Multi Adjustable Axel Plate 17" Seat Width SW17 No Charge 70 Degree Front Rigging w/aluminum flip up footplate 18" Seat Width SW18 No Charge Heel Loops 19" Seat Width SW19 No Charge Push to Lock Wheel Locks 20" Seat Width SW20 No Charge Aluminum Seat Pan A 21" Seat Width (Weight Limit 350 lbs.) sw21hd1 $475 Prism Ideal Cushion A 22" Seat Width (Weight Limit 350 lbs.) sw22hd1 $475 Adjustable Orion Back A,B 23" Seat Width (Weight Limit 350 lbs.) sw23hd1 $685 Two way Padded, Contoured Headrest A,B 24" Seat Width (Weight Limit 350 lbs.) sw24hd1 $685 Anti-tippers 4 SEAT DEPTH 15" Seat Depth SD15 No Charge 16" Seat Depth SD16 No Charge 17" Seat Depth SD17 No Charge 18" Seat Depth SD18 No Charge 19" Seat Depth SD19 No Charge 20" Seat Depth SD20 $110 21" Seat Depth SD21 $225 22" Seat Depth SD22 $225 23" Seat Depth SD23 $225 24" Seat Depth SD24 $225 T EZ Tilt Option AL4 No Charge Choice of 2 colors - Black or Silver FOOTNOTES: A. Heavy Duty Package consisting of gusseted frame B. Quick release axles are used on 23"-24" wide chairs. R. Add 9.5" to seat width of chair on finished product (handrim to handrim) T. EZ Tilt option recommended on seat depths of 20" or higher

2 Page 2 of 6 ORION II FRONT SEAT TO FLOOR HEIGHT MATRIX 5 SEAT-TO-FLOOR HEIGHT (up to 350 lbs. weight capacity) - Orion II C D D 13.25" Seat to Floor (20" Wheels and 4" Casters) 115STF01 $ " Seat to Floor (20" rear and 5" casters) 115STF02 No Charge 15" Seat to Floor (20" Wheels and 5" Casters) 115STF03 No Charge 15.5" Seat to Floor (22" Wheels and 5" Casters) 115STF25 No Charge 15.5" Seat to Floor (12" Wheels and 6" Casters) 115STF26 $ " Seat to Floor (20" Wheels and 5" Casters) 115STF27 No Charge 16" Seat to Floor (12" Wheels and 6" Casters) 115STF28 $ " Seat to Floor (24" Wheels and 6" Casters) 115STF29 No Charge 3 16" Seat to Floor (22" Wheels and 6" Casters) 115STF06 No Charge 16 1/2" Seat to Floor (24" Wheels and 6" Casters) 115STF30 No Charge 16 1/2" Seat to Floor (24" Wheels and 7" Casters) 115STF31 No Charge 16 1/2" Seat to Floor (22" Wheels and 7" Casters) 115STF08 No Charge 17" Seat to Floor (24" Wheels and 7" Casters) 115STF32 No Charge 17" Seat to Floor (22" Wheels and 8" Casters) 115STF33 No Charge 18" Seat to Floor (24" Wheels and 8" Casters) 115STF11 Standard 4 19" Seat to Floor (24" Wheels and 8" Casters) 1" Spacer 115STF34 No Charge 20" Seat to Floor (24" Wheels and 8" Casters) 2" Spacer 115STF35 $110 6 REAR WHEEL RIM Mag Wheels 115RW09 No Charge C. Only available with pull to lock brakes. D. With 12" rear wheel you can only have 7 REAR WHEEL TIRE push to lock brakes. Airless (Solid Rubber) RT1 Standard Pneumatic RT2 No Charge 8 HANDRIM OPTIONS Chrome HR1 Standard Plastic Coated HR2 $160 Omit Handrims HR3 less net $15

3 Page 3 of 6 9 ARM TYPE T-Style Adjustable Height AR04 Standard T-Style Adjustable Height Pin Release - Youth AR05 $125 T-Style Adjustable Height Pin Release - Adult AR06 $125 T-Style Fixed Height AR02 $125 Flip Back Adjustable Height AR10 $125 2-point Fixed Height Heavy Duty Arm AR13 $ ARM PAD Desk length Vinyl 10" (pair) AP1 No Charge Full length Vinyl 14" (pair) AP2 No Charge 11 PUSH OPTIONS Canes & Stroller Bars Fixed High SP2 No Charge Canes & Stroller Bars Fold Down High SP4 $250 Stroller Bars Fixed High SH2 No Charge Stroller Bars Adjustable Angle Fold Down High SH4 $250 Canes & Stroller Bars Recline High SP6 $500 Stroller Bar Recline High SP12 $500 Back Cane Angle (83, 90, 97, 104,111) Specify 115BA1 No Charge 12TRIGGER LOCATION Trigger Location - Push Cane TH1 No Charge Trigger Location - Stroller Bar TH2 No Charge A1 Foot Tilt Release (Mounted onto left side) TH3 $95 A1 Foot Tilt Release (Mounted onto right side) TH4 $95 13 BACK OPTIONS (CHOOSE ONE) E 14 BACK PINS Orion Back (16", 18", 20") available height only BK00 No Charge Omit Back BK49 less net $30 S Longer Pins for Back Hardware 1" Growth BP1 $50 S Longer Pins for Back Hardware 2" Growth BP2 $50 15 SEAT OPTIONS (CHOOSE ONE) Seat Pan SE1 Standard Prism Ideal Cushion - Stock Sizes SC01 Standard Prism Ideal Cushion - Non-Stock Sizes SC02 No Charge Prism Ideal Cushion Custom on chair SC03 No Charge FOOTNOTES: Omit Cushion SC20 less net $10 E. Height adjustability of 4" and depth adjustability of 1" G. Please refer to Backs order form for stock, non-stock, bariatric and custom sizes H. Includes Swingway Calf Pads I. Not available with 7" or 8" casters when footboard is facing back on 90 degree swingaway J. Swingaway Calf Pad can only be assembled onto Swingaway front rigging.

4 Page 4 of 6 16 FRONT RIGGING 70 Degree Pin Style FR01 Standard 80 Degree Pin Style FR02 $ Degree Swingaway Upgraded FR03 $ Degree Swingaway Upgraded FR04 $ Degree Swingaway Upgraded FR05 $ Degree Dual Swingaway Upgraded FR06 $ Degree Dual Swingaway Upgraded FR07 $ Degree Dual Swingaway Upgraded FR08 $ Degree Dual Swingaway Upgraded FR09 $230 H Elevating Legrest (pair) FR10 $550 H Dual Swingaway Elevating Legrest (pair) FR25 $580 Omit Front Rigging FR11 less net $20 Omit Footrest Hanger FR12 less net $10 17 FOOTPLATE TYPE Composite Flip Up Footplates Small FP01 No Charge Composite Flip Up Footplates Large FP02 No Charge Aluminum Flip Up Footplates Medium FP05 Standard Aluminum Flip Up Footplates Large FP06 Standard Composite Angle Adj. Flip-Up Footplates Small FP08 $120 Composite Angle Adj. Flip-Up Footplates Medium FP09 $120 Composite Angle Adj. Flip-Up Cone Lock Large FP16 $150 Composite Angle Adj. Flip-Up Cone Lock X-Large FP17 $170 Aluminum Angle Adj. Flip Up Footplates Medium FP11 No Charge Aluminum Angle Adj. Flip Up Footplates Large FP12 No Charge Composite Angle Adj. Flip-Up Footplates Spring Return Lg FP04 $150 I One Piece Footboard (15"-20") FP19 $160 I One Piece Footboard (21"-24" Custom) FP20 $195 Aluminum Angle Adj. Flip Up Footplates Small FP10 No Charge 18 FOOTREST /LEGREST ACCESSORIES Heel Loops FA01 Standard Omit Heel Loops FA02 less net $7 Padded Calf Strap FA03 $70 A1 Foam Guard on Elevating Legrest (pair) FA05 $70 FOOTNOTES: A1 Foam Pad One Piece Footboard FA06 $50 K. Only availa 27V Plugin Battery Charger, A1 Foam Pad on Footplate (pair) FA07 $70 L. Not availab 24V Battery/Control Box, M. Weight CapCompact Actuator with 135 mm 19 WHEEL LOCKS is 250 lbs. (5.31") Stroke Length Push-to-Lock Wheel Lock WL1 Standard Orion II chairs with seat width of 15" to 20" Pull-to-Lock Wheel Lock WL2 $40 Power Tilt provides approximately 42 Wheel Lock Extension WL3 No Charge degrees of infinite tilt (3 to 45 ) Attendant Wheel Lock (Foot Activated) RT WL8 $195 Includes: 2 Button Hand Control, Attendant Wheel Lock (Foot Activated) LT WL9 $195 N. Transit Hooks can only be used on Berner Push Wheel Lock WL14 $95 Orion II wheelchairs up to 350 lbs. weight Berner Pull Wheel Lock WL15 $95 capacity. Tested in accordance with 20 HEADREST HARDWARE OPTIONS Fixed Headrest Hardware HE01 No Charge Fixed Headrest Curved Hardware HE15 No Charge Fixed Headrest Hardware (Plus 4") HE02 $20 Fixed Headrest Curved Hardware (Plus 4") HE16 $20 ANSI/RESNA WC/19 FOOTNOTES: 21 HEADREST FOAM PAD OPTIONS H. Includes Swingway Calf Pads Small Headrest Foam Pad HF1 No Charge I. Not available with 7" or 8" casters A1 Small Headrest with Wings Foam Pad HF2 $90 when footboard is facing back on 90 degree Medium Headrest Foam Pad HF7 No Charge swingaway A1 Medium Headrest with Wings Foam Pad HF8 $90 Large Headrest Foam Pad HF3 Standard A1 Large Headrest with Wings Foam Pad HF4 $95 A1 Pro-Fit Small Headrest HF12 $100 A1 Pro-Fit Medium Headrest HF13 $105 A1 Pro-Fit Large Headrest HF14 $110 Omit Headrest HE09 less net $10

5 Page 5 of 6 21 HEADREST ADAPTOR BRACKETS FOOTNOTES: 2 - Hole Headrest Adaptor Bracket with Clamp HEBA2 No Charge K. Only available with Stroller Bar push option. A1 Universal Headrest Adaptor Bracket with Clamp HEBA $61 L. Not available with Flip Back Arms M. Weight Capacity of Orion II with Power Tilt 22 ANTI TIP is 250 lbs. Power Tilt can only be placed on Quick Flip Anti-Tippers MA23 Standard Orion II chairs with seat width of 15" to 20" Power Tilt provides approximately MISCELLANEOUS ACCESSORIES degrees of infinite tilt (3 to 45 ) Tilt Locking Collar MA01 $20 Includes: 2 Button Hand Control, Recline Locking Collar MA02 $20 N. Transit Hooks can only be used on Auto Seat Positioning Strap MA03 $52 Orion II wheelchairs up to 350 lbs. weight Padded Lap Tray 15"-16" MA09 No Charge capacity. Tested in accordance with Padded Lap Tray 17"-18" MA10 No Charge ANSI/RESNA WC/19 Padded Lap Tray 19"-20" MA11 No Charge Padded Lap Tray 21"-22" MA12 No Charge 27V Plugin Battery Charger, Padded Lap Tray 23"-24" MA13 No Charge 24V Battery/Control Box, Half Padded Lap Tray, left side MA14 No Charge Compact Actuator with 135 mm Half Padded Lap Tray, right side MA15 No Charge (5.31") Stroke Length A1 Elbow Stop, left MA16 $55 A1 Elbow Stop, right MA17 $55 K A1 Shoulder Lateral Pad (each) MA18 $90 L A1 Adjustable Side Pad MA19 $157 WARRANTY A1 IV Pole, telescopic MA20 $168 Future Mobility Healthcare warrants the A1 Oxygen Tank Holder MA21 $173 Orion II to be free from defects in materials A1 Quick Release Axle AL1 $110 and workmanship for a period of one (1) A1 Spoke Guards available on 20", 22" and 24" wheels MA49 $130 year from the date of purchase. The frame is N A1 Orion II Front and Rear Transit Hooks MA30 $250 warranted for the lifetime of the original purchaser and/or user. The batteries required for Power Tilt are warranted for six (6) months while the control box, battery charger, actuator and hand control are warranted for one (1) year. * Options marked by an asterisk are not covered by AADL and are the client's financial responsibility.

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