Information Request Form

Tell Us How We Can Best Help You


Are You Looking for an Outdoor Vehicle?
Do You Now Own an Electric Scooter or Power Chair?
What Kind?
When Purchased?
Have You Had Any Problems With It?
What Type of Problems?
Are You Disabled?
What Is Your Disability?
Do You Drive a Motor Vehicle Now?
How Young Are You?	0-18	19-50
How Young Are You?	50-75	76-102+
What Would You Use This Product For?
How did you find us? Required so we can send you the correct liturature.

Please check the item(s) that interest you the most. We will send a brochure via surface mail. Postage is free for addresses with a US Postal Zip. Don't forget to hit Submit when finished. Be assured, WE DO NOT SELL OR GIVE YOUR NAME, TELEPHONE NUMBER, OR EMAIL TO ANYONE!!

PLEASE do not use this page to order parts, or ask for technical assistance; use the following email address palmer@palmerind.com or call 1800-847-1304.

To view the products in action please click on the following movie clip.

Note: Due to high postage costs we do not send all of our literature so please choose only what interests you most. Thank you for helping us save trees!

PLEASE NOTE: IF YOU MARK MORE THAN (1) ONE ITEM, YOU WILL GET THE ALL PRODUCT BROCHURE.

Palmer Independence & Palmer Twosome
Palmer Hybrid
Palmer Threesome
Palmer Foursome
Palmer Yardcart
Palmer Attachable Hub Motor Kits for Bikes & Trikes
Adult Pedal Trikes with or without Electric Hub Motor
Small Portable Scooters
Palmer Handcycle
Zip-E Hub Motor for Manual Wheelchair
Palmer Electaride Hub Motor Powered Men's Mountain Bike

Please Fill in the following information so we know where to send the information!
Email:
Name:
Address:	State:	Zip:
City:

Telephone Numbers	(Home):		(Work):

Comments:

Make Sure you Click Submit/Send Request Button at Least Once. If you need technical assistance; please do not use this form.

STOP!! ONLY HIT SUBMIT IF YOU WANT A BROCHURE!! We do not sell or give out your information.

Tell Us How We Can Best Help You