customer contact details - bike-on
TRANSCRIPT
SERIAL NO: _ ______________
PROD DATE: _______ / _____
Customer Contact Details
Customer Name: Ship to Customer Address:
Advisor: Shipping Name:
Address: Shipping Address:
Phone: Phone:
Email: Email:
Additional Information
Notes: Current Wheelchair:
Customer Weight:
Customer Height:
Customer Disability:
Other
I declare that I am chronically sick or disabled by reason of:
I would like to be contacted by RGK:
Signature: Date: Signature: Date:
VAT Excemption Declaration (UK Only): RGK Contact Authorisation:
From time to time, RGK would like to send you exclusive information, news and
offers on everything RGK, by email or post. We will not pass any of your details to
any third party.
and that I am receiving from RGK Wheelchairs Ltd, the wheelchair specified
herein and I claim relief from Value Added Tax under group 12 of schedule 8 to
Value Added Tax Act 1994.
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
Guide:
Base product Required option Optional Extra Critical Information Information Needed
SBTXZ011
XA070 Open design
Max User Weight 110kg (242lbs)
Yes, I am within the max user weight
XW010 CAD drawing for approval XW011 CAD drawing for approval in 48 hours
XY010
XY020
XY030 Extra seat length (Provides additional leg support & hand grip)
XY050
XY060
XY070
(Min = XY020 + XY030 + 140mm)
XY072
Optimise measurements
XA020 Ergonomic seat
Specify length(Standard = 120mm)
PRODUCT STYLE
(Max - 440mm total seat)
KEY MEASUREMENTS
mm(Max - 440mm)
Seat width (Inside of sideguards)
(Min - 250mm)
$135.00
CAD APPROVAL
$203.00
$66.00
OCTANE SUB4
Front frame height
Seat length
mm
mm
Castor position
mm
(Max - 520mm)(Min - 380mm)
Rear frame height
(Max - 625mm)
(Max - 440mm)(Min - 250mm)
mm
$7,148.00
mm
mm(Max - 500mm)(Min - 360mm)
Frame length
mm
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
XY080 Seat taper design XY091 Parallel taper design
Specify width Specify width
XY100 Round design XY105 Square design
*Non certified Sub4 option
XY115 Front footrest height
XY120 Rear footrest height
Std = 20mm lower than front height
XY125 Footrest length
Maximum length 140mm (Certified weight)
(160mm and over requires heavy duty upgrade XB150)
XB010 XB020 Tubular titanium footrest
(Height adjustable) (Height adjustable)
(*Non-certified option*)
XB045 Lightweight carbon fibre cover Footplate width Sub4 certified (With weight saving cut-out) (Std if no option selected)
Footplate width Standard (optimised plate width) *non certified Sub4 option
FRONT FRAME AND FOOTRESTFront Frame Options
mm mm
(When combined with
XY080, dimensions must be
smaller by 20mm)
Footrest Design (Choose one)
(When combined with
XY091 , dimension is
inbetween the centre of the
main bends)
mm
Castor Wheel
Size
Max Height
Achievable
4" 110mm
Castor Wheel
Size
Max Height
Achievable
4" 130mm
Footrest Measurements
Footrest Cover
mm
mm
Footrest Style
Tubular aluminium footrest
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
XC135 Aluminium centre 4"x1.25"
Choose colour below:
XC190 Low ride castor fork
Note: colour follows accent
XY330 Castor pin width
SBTXD036 Compact scissor with lightweight fixing XD010
XE055 XE065 Screw on lightweight carbon fibre w/fender
Level with tyre (Follow tyre)
Centre of tyre
Sideguard Measurements
Screw on lightweight carbon fibre
Sideguard Measurements
CASTOR WHEELS, FORKS & WHEEL LOCKSCastor Wheels
Castor Forks
Castor Pin Width
Wheel Lock Options
Silver hub & black tyre (Std) Green hub & black tyre
Optimise measurements
(Minimum width for clear castor rotation and
maximum wheelbase length)
mm
10mm above tyre
(Standard)
Individual above tyre
Black hub & black tyre Red hub & black tyre
Purple hub & black tyre Blue hub & black tyre
Sideguard without Fender
(Min = 10mm)
Omit wheel locks
Individual above tyre (Follow tyre -
max. 25mm)
mm
SIDEGUARDSSideguard with Fender
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
XY230 XG010 Fixed Backrest (non-folding)
Specify height
XY360 Backrest angle XG100
-5 -3 0
Individual
XG110 Inward taper XG120 Outward flare
XY390 Camber angle SBTXH100
1 2 3
Specify length
SBTXN030 Beadblast frame SBTXN050
Black accent Silver accent XN250 Individual Accent Colour
Red accent Blue accent
Purple accent Carbon accent
(Castor caps only, black for rest)
XP045
XP035 Airtech Sub4 backrest strap adjustable XP050 Airtech backrest strap adjustable
*Non Sub4 option
Silver Black Blue
Red Light blue Purple
White (Std) Black Blue
Red Light blue Purple
Backrest Upholstery Logo Colour
Individual:
$66.00 $66.00
mm mm
CAMBER BAR
Frame and Footrest
mm
FRAME FINISH OPTIONS
(25-125mm)
Camber Angle
Deg
Vertical height
+3
Backrest Upholstery Stitching Options
Individual:
Single post fixed centre of
gravity
Centre of Gravity
Accent Colour (Choose One)
Polished frame
Note: Accent colour includes forks & decals.
UPHOLSTERY
$143.00
Seat Upholstery
Sub4 Seat sling strap adjustable
Backrest Upholstery
BACKRESTBackrest Height - Fixed
Backrest height
mm
Specify width or per side Specify width or per side
(inside of backrest posts)
Ergonomic Options
Ergonomic backrest
$66.00
(inside of backrest posts)
(Max -10/+20 Deg)
mm
+5
mm
Rearward position
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
XY420 XY430 25" Wheels
XY460
25
XK075 SBTXK150 Spinergy CLX 18 carbon blade spoke
(N/A with silver hub) (N/A with silver hub)
XK226 Titanium 100mm quick release axle pins
Spinergy Colour Options:
XK180 Individual spoke design(Specify colour)
Inside:
Outside:Spinergy Anodise Options
XK190 XK200 XK201 XK204 Individual hub/rims
(std option) (n/a with BLXL/CLX) (LX, XLX & BLXL only) Select colour:
XK202 XK203 XK204
(LX, XLX & BLXL only) (LX, XLX & BLXL only) (LX, XLX & BLXL only)
SBTXK040 Supply without Wheels Wheel Type: Tyre Type:
XY480 Narrow set handrim XY485 Wide set handrim
XL090 Remove excess mounting tabs
(recommended for small wheel gaps)
XL010 Aluminium hard anodised 6 tab
XL160 Elipse 6 tab XL040 Titanium 6 tab
(replacement for Surge)
XL020 Tetra grip 6 tab XL050 Stainless steel 6 tab
XL100 Para grip 6 tab XL140 Ergo gripp 6 tab wide
XM060 Schwalbe One (Lightest option)
XM010 Kenda Grey Blue Red
XM020 Schwalbe Marathon Plus XM130 Kenda black
XM040 Shox solid airless XM050 Kenda K885 mountain bike tyre (24",25" only)
XY500 Schraeder inner tube valve XY490
(Standard if no option selected)
$203.00
Supply Without Wheels
$110.00
Handrim Styles
$200.00
-$414.00
Purple hub/rims Blue hub/rims Gold hub/rims
$154.00 $154.00 $203.00
REAR WHEELS (* non certified weight options)
Black spokes White spokes Yellow spokes$146.00
Rear Wheel Size
24" Wheels
Spinergy BLXL 18 blade spoke
Rear Wheel Options
Rear Wheel Gap
Rear wheel gap
2015
Silver hub Red hub/rims
$76.00 $154.00
$57.00
$93.00
* Indicates items that are not part of the certified weight of the Tiga Sub4
Presta inner tube valve
Inner Tube Valve Options
$22.00
$15.00
$79.00
Tyre Options
$583.00
Handrim Position / Options
$84.00
$281.00
$236.00
$236.00 $245.00
Red spokes Blue spokes Pink spokes
Purple spokes Orange spokes Green spokes
Black hub
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
XP080 Cushion foam
(select density and size below)
Soft (CMS040) Medium (CMS050) Hard (9lb recon)
50mm 75mm 100mm
XP085 Nylon cushion cover
(Black)
XP090 Airlite cushion cover
(Black)
XP100 Leather cushion cover
(Black)
JAY Cushion
(Price dependant on size / option)
JAY Backrest
(Price dependant on size / option)
JAY Whitmyer Headrest
(Price dependant on size / option)
XR060 Welded calf strap mounting loops
(To locate calf strap on front frame)
Specify height from floor
Optimise measurements
XR080 Frontwheel assembly
(Only with XB010, TGAXB080, XB150)
XP120 Frame protectors Neoprene zip fasten (Black)
XP420
XR010 Seat pouch velcro attach (Black)
XR200 Rucksack with RGK logo (Black)
XR020 Underseat large storage bag (Black)
XR090 Tool kit
XS065 Sub4 Calf Strap
Frame protectors Nylon velcro fasten (Black)
$40.00
Refer to Jay Order Form
** indicates options that, when chosen, will not enable RGK to guarantee a Sub4kg product weight
$31.00
$74.00
$53.00
FRAME OPTIONS (** non certified weight options)
$81.00
$606.00
ACCESSORIES (** non certified weight options)
$58.00
Cushion cover upgrades
CUSHION (** non certified weight options)
$69.00
Cushion foam options
Refer to Jay Order Form
$54.00
$176.00
Jay Products
Refer to Jay Order Form
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SERIAL NO: _ ______________
PROD DATE: _______ / _____
XB200 High level footrest Indicate front footrest height:
XC150 Aluminium centre 3"x1.4" XC145 Aluminium centre 6"x1.4"
(Silver hub and black tyre) (Silver hub and black tyre)
XC140 Aluminium centre 5"x1.4"
(Silver hub and black tyre)
XD020 Underseat scissor XD050 Push to lock
XE030 Screw on aluminium, indicate size on page 4
SBTXG020 Folding backrest with 2 position snap lock and angle adjust
XG070 Screw in push handles XG080 Flip down push handles
SBTXH130 Square back adjustable centre of gravity SBTXH140 Round back adjustable centre of gravity (25-125mm) (60-125mm)
XJ100 Single sport anti tip
(required to change to Adjustable axle)
XR050 Carbon fibre seat plate
XP070 Backrest upgrade to leather corners (Black)
(only with Airtech upholstery XP050)
XP110 Backrest with zip pocket XP170 Individual backrest embroidery
(Please provide .jpeg file and positioning)
Push handle Options
Backrest Options
$275.00
$305.00 $305.00
$198.00
$365.00
Anti-Tip Options
$129.00
Centre of Gravity
Seat Plate
$281.00
Backrest Upholstery Leather Options (only with XP050)
$100.00
** indicates options that, when chosen, will not enable RGK to guarantee a Sub4kg product weight
Backrest Accessories (only with XP050)
$74.00 $113.00
OTHER (** non certified weight options)
$117.00
Footrest
mm
$146.00
Sideguards
Wheel Lock Options
Castor Wheel Size
$105.00 $105.00
$105.00
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SERIAL NO: ________________
PROD DATE: _______ / _______
NOTES
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