Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone *

(###)

###

####

Bottom

Mesh

Solid

Caster Size

(All hard rubber)

3"

4"

5"

Casters

Swivel

Fixed

Are you using straps with steel rings?

If yes, add diameter of ring in the space provided below

Yes

No

Are you using just straps?

Yes

No