| 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.)
Print and fax this form at (001) 450-227-8821. You could rich Dan Lavallee by phone on business time (-7:00). Phone: (001) 708-939-2466
Name
First Name
* With which rehabilitation center are you connected?
If aplicable: Tax Identification Number/EIN (IRS or
TVA)
Delivery Address
City
* Province
or State
ZIP / Postal code
Country
Complete telephone number that includes
all regional codes, for example 001.702-298-7651
Fax
*
Email
Part II
Part III
Use the box below for comments, suggestions
and questions.We can help you determine the
most suitable life jacket for the user. In your own words, describe
the person's behavior in water while wearing a floatation device.
INFORMATION
NEEDED TO OBTAIN A PRICE
PAYMENT INFORMATION 
HELP CHOOSING A LIFE JACKET
In the two days 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 / US 7,255,621
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