Info&Order for life vests

Life Jacket-Adapted PFD-A Inc.
INTERNATIONAL

Part I
In the first section, only the fields marked with an *are obligatory.
If you wish to order or pass word or to obtain a price, all fields are necessary.

Name

First Name

* Obligatory: With which rehabilitation center are you connected?

Tax Identification Number/EIN (IRS or TVA) :

Delivery Address

City

* Province or State

* Postal Code

* Country

Complete Telephone Number that Includes the International Code,
for example 011.33.(0)2.98.76.51.2 or 001-514-803-8821

Fax

* Email

Part II

product 1

Please supply some information
about the user

Height (specify inches 'in' or centimeters 'cm' )

Weight (specify pounds 'lbs' or kilograms 'Kg' )

Age (than 10 years old)

Which product do you wish to order

Product (ie: PFD-A 40-90 lbs)

Quantity

product 2

Please supply some information
about the user

Height (specify inches 'in' or centimeters 'cm' )

Weight (specify pounds 'lbs' or kilograms 'Kg' )

Age (than 10 years old)

Which product do you wish to order

Product (ie: Lj-A 45-70 lbs)

Quantity

Part III

Use the box below for comments, suggestions or questions.

PAYMENT INFORMATION

Within 24 hours following reception of the completed form, we will contact you by email or by telephone.

Patent No.: US 6,537,119 B2 / CA 2,265,112

Life jacket-Adapted PFD-A Inc.
INTERNATIONAL