Complete the form below to send a quote request directly to our sales team. Please allow 48 hours for the quote to arrive in your email. 

If you are unsure of what parts are needed, please contact our sales team at (207) 512-8009 Ext. 200 to discuss the prescription.

Quotes can only be sent to Certified EMC Dealerships. If you are not a certified EMC dealer, please contact our sales team before requesting a quote. 

Downloadable Vehicle Order Form

Custom Orthotic Catalogue

 

Request A Quote

Request A Quote

Name
Name
First
Last
End User's Name
End User's Name
First
Last
Evaluator's Name
Evaluator's Name
First
Last
If the vehicle has not been purchased, please enter a VIN of a vehicle with the same trim level.
Has this vehicle been purchased?
Ignition Type
Gas/Brake Standard Orthotic
Steering Standard Orthotics
Joystick Standard Orthotics
Round Knob, Oval Knob, and Pin automatically included with Joystick.
Switch Options
1.25", 2.5", and 5.25" diameter.
Mounting Brackets
Stand Alone Secondary Systems
Additional Accessories (*Not Automatically Included)
• Dimmer Hi/Low • Headlights On/Park/Off • Wipers Low/Hi/Wash • Dome Light • Ignition Accessory • Starter • Remote Start • Cruise On/Set • Park Brake • Programmed AUX 1 • Programmed AUX 2 • Programmed AUX 3 • Programmed AUX 4 • Left Turn • Right Turn • HVAC Temp Up/Down • HVAC A/C • Front Fans Up/Down • HVAC Vent Mode • Left Window Up/Down • Right Window Up/Down • Horn • A.I. Commander Activation • Locks
Where will this equipment be installed?
If this order requires a pre-designed orthotic from the Custom Design Catalogue or a brand new design, please indicate the number or a description. The catalogue link can be found at the top of this page.
Where will the Chassis be installed?