BNSE MOBILITY HARMAR MOBILITY PRODUCTS

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CUSTOMER INFORMATION PROFILE

First Name Last Name

Email Address

Contact Address:

Address Address

City State Zip Code

Contact Phone no: Best Time to Call

Delivery Address: (Same as Contact Address ) (Needed for Shipping Quote)

Address Address

City State Zip Code

Contact Phone no: Best Time to Call

Vehicle Information for attachment of Lift or Ramp

Manufacture Model Year

Own Leased Equipped with Class II Hitch or Class III Hitch

If no Hitch Installed do you need a recommendation for a Class II or Class III Hitch Manufacture Hitch Class Type

CUSTOMER MESSAGE TO BNSE MOBILITY

PLEASE ENTER ANY ADDITIONAL INFORMATION ON YOUR MEDICAL LIFT OR RAMP EQUIPMENT NEEDS

NOTE: WE DO NOT SELL, OR GIVE AWAY CUSTOMER INFORMATION TO ANYONE, YOUR INFORMATION IS ALWAYS KEPT PRIVATE.

Mobility Reimbursement Program
MANUFACTURERS' VEHICLE LIFT REBATE PROGRAMS
GET UP TO $1,000 IN CASH TOWARD ANY LIFT OR RAMP

General Motors, Saturn, Ford, Chrysler and Toyota offer up to a $1,000 direct, cash reimbursement when you buy a Harmar Mobility scooter or power chair lift, or Safety Ramp. The manufacturer rebate programs help people with disabilities obtain lifts and ramps for new vehicles, whether they are purchased or leased.

GENERAL MOTORS
GM's mobility program reimburses customers a maximum of $1,000 for lifts and ramps, including installation or re-installation, on eligible GM vehicles. Information on the program is available from the GM Mobility Assistance Center through the toll-free number 800.323.9935. (TTY users call 800.833.9935)

SATURN
Harmar lift and ramp buyers will be reimbursed up to $1,000, including installation or re-installation, for equipment on an eligible Saturn vehicle. Program information is available from the Saturn Mobility Program at 800.553.6000. (TTY users call 800.833.6000)

FORD MOTOR COMPANY
Ford and Lincoln-Mercury dealers, through the Ford Mobility Motoring Program, will provide up to $1,000 for lifts and ramps, including installation or re-installation, in any purchased or leased new Ford or Lincoln-Mercury vehicle that is eligible. The Ford Mobility Motoring Program provides toll-free information at 800.952.2248. (TTY users call 800.833.0312)

DAIMLERCHRYSLER
The DaimlerChrysler Automobility Program provides a cash reimbursement of up to $1,000 for the installation of lifts and ramps in full-size Ram Vans, Ram Wagons and Mini-vans. All other DaimlerChrysler Corporation cars and trucks are eligible for reimbursements up to $750. For information about the DaimlerChrysler program, call toll-free at 800.255.9877. (TTY users call 800.922.3826)

TOYOTA
The Toyota Mobility Program gives people who buy or lease vehicles up to $1,000 for the purchase and installation of lifts and ramps on eligible Toyota vehicles. For information about the Toyota program, call 800.331.4331. (TTY users call 800.443.4999)

LEXUS
Lexus reimburses customers up to $1,000 for the cost of lifts and ramps on all new purchased or leased Lexus vehicles. Information about the Lexus program is available at 800.255.3987 (TTY users call 800.443.4999)

VOLKSWAGEN
Customers who buy or lease Volkswagens are eligible for up to $1,000 for lifts and ramps. Information on the program is available from Volkswagen at 800.374.8389.

STATE OF TEXAS
Residents of Texas who need mobility assistance can be exempted from motor vehicle sales and use taxes on new or used vehicles when lifts and ramps are installed for a driver with a disability. The state sales tax on a lift or ramp, and installation charges, also may be exempted. Claims may be filed after the purchase. Contact the Texas State Controller's Office at 800.252.5555 for information about the program.

OTHER MANUFACTURERS

AL100 SCOOTER LIFT	AL500 ELECTRIC WHEEL CHAIR LIFT	SWING AWAY OPTION FOR AL100 AND AL500	AL600 UNIVERSAL HYBRID PLATFORM LIFT
AL610 HYBRID ELECTRIC WHEEL CHAIR LIFT	AL650 HYBRID ELECTRIC WHEEL CHAIR LIFT	AL055 ECONOMY INSIDE LIFT	AL065 UNIVERSAL HYBRID INSIDE-OUT LIFT
AL200 UNIVERSAL INSIDE LIFT	AL400 PREMIUN GRADE HEAVY DUTY FULLY POWERED INSIDE LIFT	MODULAR RAMPS	MULTI-FOLD SAFETY RAMPS
SINGLE FOLD SAFETY RAMPS			MOBILITY REIMBURSEMENT PROGRAM


THREE OR FOUR WHEEL SCOOTERS LIFT
AL100
AL100	AL100 Universal Scooter Lift Specifications: Lifting Capacity 350lbs. Aluminum deck size 28.5" x 39" Installed weight 95lbs. Shipping weight 125lbs. Max. scooter width 28.5" Max. scooter wheelbase* 42" Min. hitch height 5" Max. hitch height 19"	more information check here

ELECTRIC WHEEL CHAIR LIFT
AL500
AL500	AL500 Universal Power Chair Lift Specifications: Lifting Capacity 350lbs. Aluminum deck size 28.5" x 39" Installed weight 98lbs. Shipping weight 129lbs. Max. power chair width 28.5" Min. hitch height 5" Max. hitch height 19"	more information check here

Swing Away options for AL100 & AL500 Lifts for any vehicle
The Swing Away Option available for the AL100 and AL500 allows an outside lift to be pivoted away from a vehicle to gain clear access to the trunk, lift gate or tailgate. A secure, easy-to-use latch assembly makes the Swing Away Option easy to use.
Swing Away option AL100 & AL500		more information check here

AL600
Harmar AL600 Series Universal Hybrid Platform Lifts (HPL)
The Harmar AL600 Series Universal Hybrid Platform Lifts (HPL) are the ultimate inside-loading lifts. The remote hand control powers the lifts and secures virtually any power chair or scooter into the back of most SUVs, vans, minivans and even some station wagons. Most installations use existing third-row seating mounts. They offer either the easy power chair automatic tensioners or an automatic hold-down arm for effortless securement

AL610
HYBRID ELECTRIC WHEEL CHAIR LIFT
The AL610 is the ultimate user-friendly scooter lift. One button deploys the platform for drive-on, drive-off simplicity. The remote hand-control powers the lift and automatically secures virtually any scooter into the back of most SUVs, vans, minivans and even some station wagons. Most installations utilize existing third-row seating mounts. The Al610 uses the automatic hold-down mechanism of Harmar's AL100 Universal Outside Scooter Lift. This is the best inside-platform lift you can buy.
AL610	AL610 Universal Power Chair Hybrid Platform Lift Specifications: Lifting Capacity 350 lbs. Aluminum deck size 28.5" x 39" Installed weight 175 lbs. Shipping weight 200 lbs. Headroom required 32" Platform height (dead space) 5" Lifting height 32"	more information check here

AL650
HYBRID ELECTRIC WHEEL CHAIR LIFT
The AL650 is the ultimate user-friendly power chair lift. One button deploys the platform for drive-on, drive-off simplicity. The remote hand control powers the lift and secures virtually any power chair into the back of most SUVs, vans, minivans and even some station wagons. Most installations utilize existing third row seating mounts. It features the easy power chair automatic tensioners designed for public transportation. This is the best inside platform lift you can buy.
AL650	AL650 Universal Power Chair Hybrid Platform Lift Specifications: Lifting Capacity 350 lbs. Aluminum deck size 28.5" x 39" Installed weight 175 lbs. Shipping weight 200 lbs. Headroom required 32" Platform height (dead space) 5" Lifting height 32"	more information check here

AL055
Economy Inside Lift
Our Economy Inside Lift provides the same durability and performance of our other inside lifts, at an economical price. The AL055 is a power lift with manual boom rotation for use in vans, SUVs or the trunk of most cars. Docking devices are available to accommodate today's smaller scooters and chairs.
AL055	AL055 Economy Inside Lift Specifications: Lifting Capacity 200lbs. Headroom required 37"* Installed weight 28lbs. Shipping weight 34lbs. Lifting Height 49.5" Range of Boom 360 degrees *Post may be modified for shorter heights	more information check here

AL065
Universal Hybrid Inside-out Lift
AL065	AL065 Universal Hybrid Inside-out Lift Specifications: Lifting Capacity 200lbs. Installed weight 35lbs. Shipping weight 45lbs. Lifting height Up to 44" Range of boom 100 degrees	more information check here

AL200
Universal Inside Lift
AL200	AL200 Universal Inside Lift Specifications: Lifting Capacity 350lbs. Headroom required 30"* Installed weight 39lbs. Shipping weight 49lbs. Lifting Height 49.5" Range of Boom 360 degrees *37" required with tall post upgrade	more information check here

AL400
Premium grade, heavy-duty, fully powered inside lift.
The AL400 is our premium grade, heavy-duty, fully powered inside lift. With its 350 lb. capacity, the AL400 lifts virtually every scooter and chair on the market and the motorized rotational base powers it safely into the vehicle. Universal design allows installation on either side of the vehicle and external applications such as pick-up trucks. Tall post available is for larger vehicles and offset post is available for tailgate applications.
AL400	AL400 Fully Powered Inside Lift Specifications: Lifting Capacity 350lbs. Headroom required 30"* Installed weight 61lbs. Shipping weight 71lbs. Lifting Height 34" Range of Boom 190 degrees *37" required with tall post upgrade.	more information check here

Modular Ramps
Modular Safety Ramps are designed and engineered to meet or exceed ADA codes and provide the strongest ramp systems on the market. These welded all-aluminum ramps offer strength and durability for everyday use at homes as well as many commercial applications. Capacity: Up to 1,000 lbs. per section. Safety First: Refer to your owner's manuals for recommendations concerning acceptable usage and inclines for your scooter or chair.	Pre-assembled Modular Safety Ramp Specifications: Lengths (in feet) 6, 8, & 10 x 36" wide Platform (in feet) 5 x 5	more information check here

Multi-Fold Safety Ramps
Unique hinge and curb design allows the ramp to be folded and transported in one or two lightweight pieces. No struggling with a bulky, hard-to-use ramp. Take apart spring hinges and dual handles allow easy lift and fast setup. Capacity: 725 lbs. Safety First: Refer to your owner's manuals for recommendations concerning acceptable usage and inclines for your scooter or chair	Multi-Fold Safety Ramp Specifications: Lengths (in feet) 6, 7, 8, 10, & 12 x 30" wide Capacity (all sizes) 725 lbs.	more information check here

Single-Fold Safety Ramps
Designed for lightweight portability at home or while traveling. Very easy to move, yet strong for everyday use. Capacity: 725 lbs. Safety First: Refer to your owner's manuals for recommendations concerning acceptable usage and inclines for your scooter or chair	Single-Fold Safety Ramp Specifications: Lengths (in feet) 2, 3, 4, 5, & 6 x 30" wide Capacity (all sizes) 725 lbs.	more information check here