Product Warranty Registration Form

Please fill out the information below to register your product.

Product Information
Product Category Lift Chair Scooter Power Wheelchair Adjustable Bed
Serial Number
Product Model Number
Date Purchased / MM / DD YYYY
Name of Dealer your purchased product from (if you purchased this product through the Internet please list the website address)
Dealer Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Buyer Information

All information submitted will be kept strictly confidential. We will never share your information with anyone. This information will be used solely in the event that there is a product change about which we need to notify you as the owner of a product.
Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
Agreement

I have read the owner's manual that accompanies this unit and fully understand:
Check all that apply (*where applicable) Product Warranty Information Safety Operation Care & Maintenance Adjustments For Operator Comfort Batteries And Battery Charging* The function of the freewheel levers* Only Sealed Lead_Acid or Gel Cell type batteries can be used. Batteries must be sealed, deep-cycle, and maintenance free. Any other type hinders performance and voids the warranty. * My Provider has instructed me on how to operate this product. *
Signature Agree Do Not Agree
Optional Information
Age
Weight
Height
Gender
Physical Limitations
Hobbies & Activities
Favorite Magazines & Publications
Favorite Features

Product Warranty Registration Form

Product Warranty Registration Form

Product Information

Buyer Information

Agreement

Optional Information