Text Box: Les Brazier Special Vehicles Text Box: Personal Profile Text Box: There are many variables associated with meeting wheelchair transport needs. The information collected on the  form will assist us in evaluating your needs and providing you with meaningful information. We assure you all information provided will be treated in the strictest confidence. This is page 2 of your Personal Profile, if you haven't filled out page 1 please take the time to go back to it.   Text Box: Vehicle Particulars / Requirements Text Box: The following questions will give us the needed information regarding what you require from your vehicle. Text Box: The vehicle will be required to take …….? Text Box: What is your preferred vehicle transmission? Text Box: Do you require air conditioning? Text Box: What equipment does the vehicle need to be able to accommodate? (e.g. Ramps, Folding Hoist, Folding shower/Commode chair, Respirator) Text Box: Comments: Text Box: Name & Address: Text Box: Phone: Text Box: Passengers (including driver) Text Box: Passengers (including driver) Text Box: Passengers (including driver) Text Box: Item Text Box: E-mail: Required Field:
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Personal Profile pg 1