Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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I am physically disabled or am applying for someone that is physically disabled

Yes, I am physically disabled

I am financially in need of assistance to afford this item

Yes, I am in financial need

I live in Florida

Yes, I do live in Florida

What item are you applying for?

Smart Drive Power Assist

Not A Wheelchair Rig

I certify that all of the above information is true

Yes, by clicking this checkbox I certify that all of the information on this form is true

I confirm that I am 18 years or older

Yes, by clicking this checkbox I confirm that I am 18 years or older