Complete Information Request Form

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Complete Information Package Request Form
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I am interested in:
Approx. Height:
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Do you need to access an elevator?:	No Yes
Do you need to ride on transit?:	No Yes
Do you have Extended Medical Coverage? (eg. Blue Cross, SunLife, Manulife, etc.)	If yes please specify:
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SCOOTER CITY LTD - 65B Clipper Streer, Coquitlam, BC Canada

Ph: 604-540-6373 Toll Free: 1-877-508-3322 email: info@scootercity.ca web: www.scootercity.ca