One Month Funded Trial AgreementDecember 10th, 2018
FiledDecember 10th, 2018☐ I-12+ Please Select MountTable Top Floor Stand ☐ I-15+ Please Select MountTable Top Floor Stand ☐☐ ☐☐ ☐☐☐ I-110Indi 7 Speech Case ☐☐☐☐☐ Keyguards SCF 2x2 SCF 3x3 SCF 4x4 SCF 5x5 SCF 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: