Name *

Company Name

Phone Number

Area Code Phone Number

E-mail *

Address *

Street Address
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City	State / Province
Postal / Zip Code	Country

What is the make and model of the powerchair you are fitting with Active Controls?

Other than Chin Control, Active Controls Rehab Solutions require an enhanced display to function. How do you plan to mount the display with the chair?

The display will be mounted on the drive control. I will mount the display to the drive control, but I will provide it myself. I plan to mount the display on the armrest, but I need the display included in my quote. (30470) I plan to use my existing armrest mounted enhanced display that I already have. (30470) I need a quote for a conventional Chin Control.

What type of electronics is the chair equipped with? (Needs Harnesses) *

What type of electronics is the chair equipped with? *

What type of electronics is the chair equipped with? (Selects Armrest Mounted Display) *

What control system will you be using? (For R-Net) *

JoyBar with Enhanced Display (Enhanced JoyBar) R-net Omni Display - 37602 ReJoy MicroPilot (Switch-IT MicroPilot) R-net Omni Display - 37908 ReJoy MicroGuide (Switch-IT MicroGuide) R-net Omni Display - 37926 ReJoy Touch (Switch-IT Touch Drive 2) R-net Omni Display - 37909 Active Tray with 4 Switch-IT Proximity Switches R-net Omni Display - 37914 Active Tray with 5 Switch-IT Proximity Switches R-net Omni Display - 37906 ReJoy With Stealth Mushroom Drive R-net Omni Display - 37907

What control system will you be using? (For Q-Logic) *

JoyBar with Enhanced Display (Enhanced JoyBar) Q-Logic Display - 37604 ReJoy MicroPilot (Switch-IT MicroPilot) Q-Logic Display - 37922 ReJoy MicroGuide (Switch-IT MicroGuide) Q-Logic Display - 37927 ReJoy Touch (Switch-IT Touch Drive 2) Q-Logic Display - 37921 Active Tray with 4 Switch-IT Proximity Switches Q-Logic Display - 37924 Active Tray with 5 Switch-IT Proximity Switches Q-Logic Display - 37923 ReJoy With Stealth Mushroom Drive Q-Logic Display - 37920

What control system will you be using? (For Q-Logic - Armrest Mounted Display) *

Enhanced JoyBar for Armrest Mounted Display No RAM Mount - 37605, 30470 ReJoy MicroPilot (Switch-IT MicroPilot No RAM Mount - 37912 ReJoy MicroGuide (Switch-IT MicroGuide) No RAM Mount - 37925 ReJoy Touch (Switch-IT Touch Drive 2) No RAM Mount - 37911 Active Tray with 4 Switch-IT Proximity Switches No RAM Mount - 37915 Active Tray with 5 Switch-IT Proximity Switches No RAM Mount - 37913 ReJoy With Stealth Mushroom Drive No RAM Mount - 37910

What control system will you be using? (For R-Net - Armrest Mounted Display) *

Enhanced JoyBar - 37605, 30470 ReJoy MicroPilot (Switch-IT MicroPilot) - 37912 ReJoy MicroGuide (Switch-IT MicroGuide) No RAM Mount - 37925 ReJoy Touch (Switch-IT Touch Drive 2) No RAM Mount - 37911 Active Tray with 4 Switch-IT Proximity Switches No RAM Mount - 37915 Active Tray with 5 Switch-IT Proximity Switches No RAM Mount - 37913 ReJoy With Stealth Mushroom Drive No RAM Mount - 37910

What control system will you be using? (No Display For Q-Logic) *

Enhanced JoyBar No Display Q-Logic Ready - 37601 ReJoy MicroPilot (Switch-IT MicroPilot) No Display - 37912 ReJoy MicroGuide (Switch-IT MicroGuide) No Display - 37925 ReJoy Touch (Switch-IT Touch Drive 2) No Display - 37911 Active Tray with 4 Switch-IT Proximity Switches No Display - 37915 Active Tray with 5 Switch-IT Proximity Switches No Display - 37913 ReJoy With Stealth Mushroom Drive No Display - 37910

What control system will you be using? (No Display For R-Net) *

Enhanced JoyBar No Display R-net Ready - 37601, 30404 ReJoy MicroPilot (Switch-IT MicroPilot) No Display - 37912 ReJoy MicroGuide (Switch-IT MicroGuide) No Display - 37925 ReJoy Touch (Switch-IT Touch Drive 2) No Display - 37911 Active Tray with 4 Switch-IT Proximity Switches No Display - 37915 Active Tray with 5 Switch-IT Proximity Switches No Display - 37913 ReJoy With Stealth Mushroom Drive No Display - 37910

What type of Chin Control do you want? *

Chin Control for R-net Electronics - 37905 Chin Control for Q-Logic Electronics - 37903

How Many Sockets will you need? *

1 - 30200; 30411 2 - 30200 (x2); 30410 3 - 30200 (x3); 30410

Where 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

For Pride/Quantum Power Chairs, you can have your base shipped to Active Controls for installtion of your selected drive control for a $95 installation fee. Would you like to include this in your quote as well? *

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.

Is the quote you are requesting for a Veteran / VAMC?

Yes No

Please Enter the Last Name and Last 4 Digits of the veteran's social for future identification.

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