Date:          P.O. #:              Resale #:
Contact:     Phone:     Fax:
        Bill to:                                                                     Ship to:
                 

1.  What size chest strap?
       a)  For individual users, give chest circumference in inches.
       b)  For multi-adjustable, designate:   Small (28")               Medium (28" to 36")    
                                                               Large (36" to 44")     X-Large (44" to 52")

2.  What material will be used for the chest strap? 
        4" Loop - Most commonly ordered.     2" Webbing - Recommended if chafe is not a concern.

3.  How will the Torso Support open/close?
        Closure I - hook and loop overlap, with D ring.
        Closure II - thread through and fold back, with D ring.
        Closure III - plastic quick-release buckle
        Auto Buckle - additional $6.00                               Airline Buckle - additional $6.00

4.  How will the webbing back strap attach?  Complete including ALL measurements.
        Buckle in the back.        Width of back.      Circumference of back.   
        Attach with grommets.  Width of chair.      Distance from screw to screw. 
              (Screw to screw measures across the front, following contour, including back cushion or laterals.) 
        Attach to multi-mounts-recline system.  Width of chair.   
             Distance from multi-mount attachment point across the front, following contour, including back
             cushion or laterals. 

Note:  The Torso Support is not compatible with all recline systems.  There must be a place to attach the webbing back strap that will allow the Torso Support to move with the wearer when reclining.