DEALER LOCATOR

To locate a Van Action Lifts authorized dealer in your area
please fill out the form below. Thank-you.

* Mandatory fields

First Name *
Last Name *
Company Name :
Mailing Street Address : *
Unit or Apartment # :
City / Town : *
State / Province : *
Zip / Postal Code : *
Country : *
Day Time Phone : *
Evening Phone :
Cell Phone :
Email : *
Type of disabiliy :
Selections
Controls: Right or Left Hand:	Right Hand Left hand
How will you transport your scooter:	Accessible Vehicle Public transit Accessible Taxi Other
Is your house / apartment accessible:	yes no
Therapist name :
Comments :