Adapted Life Jacket Logo

Life Jacket-Adapted Inc. INTERNATIONAL
We care about people with special needs.

Safe and reliable lifejackets designed for
people of all ages with reduced mobility.


Part I

If you only wish to get more info, please complete the *Required fields.
If you wish to order, complete the other fields as well.

Last Name

First Name

Are you affiliated with a rehabilitation Center? If yes, which one?

How did you hear from us?

Shipping Address

City

Province or State

Postal / Zip Code

Country

Phone Number, including country and area code,
for example 011.33.(0)1.23.45.67.89 or 001-514-803-8821

Fax

Email



Part II

product 1

Information about the user

Height(specify 'lbs' or 'Kgs' )

Weight(specify 'lbs' or 'Kgs' )

Age

Which product do you wish to order?

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

Quantity

product 2

Information about the user

Height(specify 'lbs' or 'Kgs' )

Weight (specify 'lbs' or 'Kgs' )

Age

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.

  


We will contact you within 24 hours of receiving your information.