Are you building a chair that has Expandable Electronics on it?*

Yes No

Name*

Company Name

Phone Number

Area Code Phone Number

Email Address*

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Does the powerchair currently have lights and actuators?*

Yes No

Does the powerchair have more than 2 Actuators?*

Yes No

How Many Sockets?*

1 - 37170 2 - 37180 3 - 37190

What size are the batteries?*

U-1 or Smaller Group 22 or Bigger

How Many Sockets?*

1 - 37110 2 - 37120 3 - 37130

How Many Sockets?*

1 - 37140 2 - 37150 3 - 37160

What type of electronics is the chair equipped with?*

Your Expandable Electronics will allow you to use the Enhanced JoyBar with a display that requires no power module swap. If you would like this please go back to the quotes section by clicking the back button in your browser and use the Active Controls Rehab Solutions quote page and Select the Enhanced JoyBar.

How will you mount the sockets?*

Front Side Rear

Front Socket Bracket*

Flip Down - 30301

Stealth Angle Adjustable - 30309

Fixed Flat - 30355

Fixed 10° Bend - 30354

Side Socket Bracket*

Stealth Angle Adjustable - 30311

Fixed Flat - 30355

Fixed 10° Bend - 30354

Rear Socket Bracket*

Stealth Angle Adjustable w/
Extension Harness - 30386

Tubular Attendant Socket Bracket w/ Extension Harness - 30378

Ship the controls preassembled on a Pride Powerchair?*

Yes No

I have / will order the powerchair from Pride Mobility Corp. and have specified the ship to:

Active Controls
597 Mantua Blvd.
Sewell, NJ 08080

I have an existing powerchair or I am going to order another manufacturer's powerchair for this quote.

Powerchair Information

Additional Comments

STOP!

Please go back to the quotes section by clicking the back button in your browser and use the Active Controls Rehab Solutions quote page and select the Enhanced JoyBar.