CONVERSION QUOTE REQUEST FORM

PURCHASE INFORMATION

PURCHASE TIME FRAME:
PRICE RANGE:

VEHICLE REQUIREMENT INFORMATION

Do you own vehicle that you wish to adapt? Yes  No
Do you intend to drive your vehicle? Yes  No
What size are you interested in? Full  Mini
Doctor's prescription for adaptive equipment? Yes  No
Sitting Height Overall Chair Width:
New or Used Van    New   Used
Hand Controls Wheelchair Lift Wheelchair Ramp Scooter Lifts
Transfer Seat Raised Roofs Remote Entry  

CONTACT INFORMATION

First Name:
Last Name:
Email:
Address:
City:
State/Country:
Zip Code
Phone Number--
Best Time To CallAM  PM

Comments:

YOUR TRADE IN INFORMATION

YES I HAVE A TRADE IN! Yes No
 
If your answer is no please scroll down to the end or  click here for your quote submission.
Year
Make
Model
Mileage
Van Converter Ramp   Lift
VIN #

SELECT YOUR VEHICLE CONDITION

Poor Fair Good Excellent
Mechanical problems or visual defects ... more Some mechanical defects, visual blemishes ... more No major mechanical defects or visual blemishes ... more Excellent mechanical condition, glossy paint, perfect interior ... more

Asking Price:

All information submitted will be kept confidential and will be used solely for the promotion or sale of submitted vehicle.

 

TOP OF PAGE

HOME

Mobility Products for the Physically Challenged

Complete Van Conversions, Driver Controls, Raised Roofs, Lowered Floors, Automobile Lifts, Scooters, Vans New and Used

In Association with Mobility Independent Transportation Systems, Inc. (MITS)
750 US 41 Venice Bypass South, Venice, FL 34292
Toll Free: 866-400-3443 Local: 941-468-3443 Fax: 941-484-1390
Ask For: Richard Miller - Mobility Manager
Problems with this site?CLICK HERE to contact the webmaster.
Copyright  © 2002-2008 Wheelchair-van.com by  Mobility Independent Transportation Systems, Inc. a FL corporation all rights reserved