519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 www.motioncomposites.com November 14th, 2011

HELIO_CANADA_V0.10EN_QS

Page 1 of 2

Order Form | shipped within 72 hours

User manual: □ English □ French

Account : PO : Ship to :

Vendor : Name :

Date : Address :

Ordered by : City: Province :

Marked for : Postal Code : Phone :

1 Ultralight manual folding helio wheelchair1

WMA3QM005 /WAMC

HELIO $3100 □

FRAME COLOR

2 Onyx black □ Sapphire blue □ NC □

SEAT WIDTH & DEPTH 3 Seat width 16” □ 18” □ NC □ 4 Seat width 20” □ WAMA HSW1 $285 □ 5 Seat depth 16” □ 18” □ NC □ 6 Seat depth 20” □ WAMB HSD1 $215 □ 1 Maximum weight limit: 250lbs

BACK CANE, include push handles 7 Lightweight carbon fiber straight back cane NC □ 8 Aluminum 8° bend back cane HBA1 $80 □ 9 Select height: 15” – 18” □ 18” – 21” □

Set height to : _____________ (measured from seat sling to top of back upholstery)

SEATING UPHOLSTERY 10 Nylon seat sling NC □

BACK UPHOLSTERY 11 Slip on back upholstery NC □ 12 Adjustable tension back upholstery WAMD/WAME HBU1 $162 □ 13 Omit back upholstery HBU2 $-15 □

FLIP BACK ARMREST 14 Full length, height 9½” – 12” HAR2 $348 □

FOOTREST 15 60° swing away footrest, 14” – 18” length adjustable HFR1 $55 □ 16 70° swing away footrest, 14” – 18” length adjustable NC □

Set length to :_______________

FOOTPLATES 17 Standard (Composite) NC □ 18 Adjustable angle oversize (Aluminum) WAMJ HFP1 $138 □ 19 One piece adjustable angle flip-up HFP2 $190 □

20 Length adjustable heel loop NC □

For the full feature Helio order form, please visit www.motioncomposites.com

519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 www.motioncomposites.com November 14th, 2011

HELIO_CANADA_V0.10EN_QS

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CASTERS

21 Composite wheel /w PU tire (1’’ width) 5” □ 6“ □ NC □

22 Composite wheel Soft-Roll® by Frog Legs

1

4” x 1 ½” HCA2 $85 □

23 5” x 1 ½” HCA3 $95 □

24 6” x 1 ½” HCA4 $105 □ 1 Soft-Roll® by Frog Legs are casters that absorb vibrations

4” caster 5” caster 6” caster

Forks Stem bolt length Stem bolt length Stem bolt length

STD +1” +2” STD +1” +2” STD +1” +2”

4” P1 14 ½ 15 ½ 16 ½

P2 15 16 17 15 ½ 16 ½ 17 ½

5”

P1

P2 15 ¼ 16 ¼ 17 ¼ 15 ¾ 16 ¾ 17 ¾

P3 15 ¾ 16 ¾ 17 ¾ 16 ¼ 17 ¼ 18 ¼ 16 ¾ 17 ¾ 18 ¾

P4 16 ¼ 17 ¼ 18 ¼ 16 ¾ 17 ¾ 18 ¾ 17 ¼ 18 ¼ 19 ¼

7”

P1 17 ¼ 18 ¼ 19 ¼

P2 17 ¼ 18 ¼ 19 ½ 17 ¾ 18 ¾ 19 ¾

P3 17 ¾ 18 ¾ 19 ¾ 18 ¼ 19 ¼ 20 ¼

P4 17 ¾ 18 ¾ 19 ¾ 18 ¼ 19 ¼ 20 ¼ 18 ¾ 19 ¾ 20 ¾

P5 18 ¼ 19 ¼ 20 ¼ 18 ¾ 19 ¾ 20 ¾ 19 ¼ 20 ¼ 21 ¼

REAR WHEELS, include quick release axle 25 Spoke 22” □ 24” □ WAMU NC □ 26 Spinergy Wire® 22” □ 24” □ WAMU HRW2 $275 □

TIRES 27 Soft urethane 1 ⅜” 22” □ 24” □ NC □ 28 Pneumatic 1 ⅜” 22” □ 24” □ NC □

HANDRIM 29 Aluminum anodized Assembly

regular □ narrow □ NC □

30 Plastic coated WAMO HHR1 $130 □

REAR WHEEL CAMBER ANGLE 31 0° camber NC □

32 3° camber NC □

WHEEL LOCK 33 Push to lock □ Pull to lock □ NC □ 34 6” removable extension handle HWL1 $32 □

POSITIONING BELT 35 Auto buckle HPB2 $40 □ 36 Hardware for 4 points seatbelts HPB3 $16 □

ACCESSORIES 37 Anti tippers HAC1 $75 □ 38 Cane Carrier left □ right □ HAC2 $85 □

Transit securement points come standard on every Helio wheelchair

Total

Wheel size Height available ± ¼”

22” wheel 13 ½” to 18”

24” wheel 14 ½” to 19”

Specify desired height: __________

REAR SEAT-TO-FLOOR HEIGHT

FRONT SEAT-TO-FLOOR HEIGHT MATRIX

Circle the desired configuration