This sheet is provided for your convenience in helping you and Adaptive Solutions Inc.in selecting the correct ramp for your needs. Please print this worksheet, fill out as complete as you can, and  fax it to 251-660-1788. If you need assistance in filling out this form, contact Adaptive Solutions, Inc.at 800-299-2045.If you are purchasing a ramp for stairs that are awkwardly staggered, please have all dimensions available.

What is the PRIMARY use for this ramp: (Home/Vehicle/Other)

_______________________________________ Will the ramp be moved often or left down in one location? ___________________________________________ Is the ramp going to be used with a scooter or with a wheelchair? _____________________________________ How much ground clearance do you have? (Measure distance from the battery pack or foot rests to the floor) ___________ What is the weight of the chair with and without the occupant?

 FOR USE WITH STAIRS: If you are planning on using the ramp for stairs, are they uniform steps (1) or staggered (2)? Landing ?

What is the height _____________ and depth of each step? ______________________________________ Are there any landings. What is the depth? ____________________________________ How much room do you have after the last (bottom) step? (ie; length of walkway) _______________________

FOR VAN/AUTO USE: For van use, will you be loading through the side or back of the vehicle? ______________________________ What is the distance from the floor of the van/trunk of the car to the ground?___________________________ Will the occupant be riding the wheelchair into the vehicle? ________________________________________ What is the width of the door opening? _________________________________________________________ How much room do you have to store the ramp in the vehicle? ______________________________________