Name: .............................................................  Male/Female: ................... Age: ......................  Address: .........................................................  Telephone: ......................................................  E-mail: ............................................................  Body Measurments:  1) Inside Leg      crutch to floor: ............................................  2) Torso: .........................................................  3) Arm: ...........................................................  4) Femur: ........................................................  5) Fore-Arm: ..................................................  6) Shoulder: ....................................................  7) Shoe Size: ...................................................  8) Height: ........................................................  9) Weight: .......................................................  Notes/Questions:

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WORKS AND SHOWROOM AT:
89 GLOUCESTER ROAD, CROYDON, SURREY CR0 2DN
Telephone: 020-8684 3370 - Fax: 020-8665 9763
www.robertscycles.com