Life Jacket-Adapted PFD-A Inc.
INTERNATIONAL

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*** If you order today, your life jacket will ship
by December 19 th
Thank you
***

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.


Patent No.: US 6,537,119 B2 / CA 2,265,112

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Life jacket-Adapted PFD-A Inc.
INTERNATIONAL