Order Date: Purchase Order Number: Contact Name: Telephone Number: E-Mail Address for Confirmation:

BILL TO: Organization: Address: City, State, Zip Code: Attention: SHIP TO: Organization: Address: City, State, Zip Code: Attention:

EVACUTION CHAIRS QTY ORDERED UNIT PRICE EXT. PRICE EVAC+CHAIR® 300H (MK-3) ____ ____@ $__________ $__________

EVAC+CHAIR ®600H __________@ $__________ $__________ IBEX® 700H __________@ $__________ $__________ AIR+CHAIR® Transit Chair __________@ $__________ $__________

ACCESSORIES

Replacement Vinyl Dust Cover ____ ____@ $__________ $__________

Comfy Seat __________@ $__________ $__________ EVAC+ALARM® Anti-Theft device __________@ $__________ $__________ EVAC+CHAIR® Patient Carrier Seat _________@ $__________ $__________ EVAC+CHAIR® Metal Storage Cabinet_______@ $__________ $__________

Shipping & Handling Charges _______ @ $__________ $__________ Total Charges $__________

NY State Tax (if applicable)

Note: EVAC+CHAIR North America LLC Is only authorized to collect sales and use tax For the State of New York. If applicable for your State or District, please remit independently.

EVAC+CHAIR® North America LLC 3000 Marcus Avenue, Suite 3E6

Lake Success, NY 11042 Tel: 516-502-4240 Fax: 516-327-8220

Internet: www.evac-chair.com E-mail: sales@evac-chair.com Our Federal ID: 26-1154735

Any Special Instructions/Comments? ___________________________________________________________________________________________________________________________

If paying by credit card (Must match BILL TO Name/Address)

Card Number

Cardholder Name and Billing Address

Expiration Date CSV#

Card Type (Visa, MasterCard, Amex)

Terms and Policies Leasing Options:

Municipal Tax-Exempt Leases for state and local government agencies. Federal Government Leases for federal government agencies including the military. Commercial Leases for small, medium and large businesses.

(Contact EVAC+CHAIR® for more details)

Return Policy:

Returned Inventory Policy: Goods may be returned within 30 days of invoice date if they do not meet evacuation requirements. Customer is responsible for cost of freight to return goods to EVAC+CHAIR® North America LLC. A restocking fee of 10% will apply. Customer will also be charged for cost of any required repairs and replacement of any missing items. Customer MUST receive a returned goods authorization number from EVAC+CHAIR® North America LLC before goods will be accepted. Terms:

Our terms are Net 15 days. Prices for EVAC+CHAIRs® are FOB warehouse plus applicable taxes. Open account is available to governmental agencies, hospitals and educational institutions and firms rated "Good" or better by Dun & Bradstreet. All others should supply two major credit references or include payment with first order. Prices, specifications and equipment subject to change without notice. We accept MasterCard, Visa and American Express credit cards on our web site order form, by telephone or fax. Sales Tax:

All orders with a New York shipping address must include the applicable sales tax on both the merchandise portion and the shipping/handling charges of your order unless you provide us with an exemption permit. Shipping of accessories is FREE with the purchase of any EVAC+CHAIR®. We maintain an extensive inventory and generally ship within five days of receipt of order. Please include your street address and ZIP or Postal Code on each order.

EVAC+CHAIR® North America LLC 3000 Marcus Avenue, Suite 3E6

Lake Success, NY 11042 Tel: 516-502-4240 Fax: 516-327-8220

Internet: www.evac-chair.com E-mail: sales@evac-chair.com Our Federal ID: 26-1154735