New Customer Registration Form

Customer Details:

Hello from the Capital Special Vehicles family and team! For us to help you decide on the best and most appropriate vehicle and conversion for you, we need help from you first. All information you submit through this form will only be used to assist us to meet your needs, and will be kept strictly confidential.
All this information relates to the person requiring the modification (the client).
Are you the client?*

YesNo
If No what is your name and relationship with the Client?
Parent, Spouse, OT, etc.
Clients Full Legal Name *

First NameLast Name
Preferred name?
Date of birth

DayMonthYear
Address*

Street Address

Street Address Line 2

SuburbState

Postal / Zip Code
Best Person to Contact
Contact Number

Area CodePhone Number
E-mail*
example@example.com
What is the preferred or best time to reach you?
E.g: Morning, afternoon
We also need to know if the client has an occupational therapist. If you do, what is their name?*

YesNo
Occupational Therapist
Occupational Therapist Contact PH number?

We need to know about yourself and your wheelchair so we can tailor the vehicle to your needs.
What is the make, model and age of your primary wheelchair?
Make Make* Model Model*
Year Year
Wheelchair*

ElectricManual
A:A*
B:B*
C:C*
D:D*
E:E*
F:F*
G:G*
H:H*
I: I*
Wheelchair occupant*

ChildAdult
Is the wheelchair occupant planning to drive or be a passenger?*

DriverPassenger
Is your intended vehicle to be a self-drive from the wheelchair or can the driver transfer into the driver’s seat?

Self DriveDrive Transfer
Please tell us about any other wheelchairs you may have?
Weight of wheelchair occupant and wheelchair to determine which lift/ramp will suit the applicant*
Let us know a bit more about you.

You may find these questions strange when buying a vehicle, and these questions are entirely optional. If you choose to answer these questions, they will help us make sure we can tailor the vehicle to your needs.

What will you primarily be using the vehicle for?
E.g: Travelling to work, family trips, etc.
What number of family, friends, carers will be travelling in the vehicle with you at any one time?
Do you have any special hobbies or interests? Letting us know can help us tailor the vehicle to your lifestyle.
Where will the vehicle be parked primarily?
E.g: Garage, carport
Will you use the vehicle for towing?

YesNo
if Yes, what will you be towing?

To help us comply with our legal requirements, we need to know about any funding body you may be involved with.
Are you involved with any of these funding bodies?*

iCare (Lifetime Care and Support)NDISTACWorkCoverN/AOther
If you are involved with a funding body, we need to know your claim or participant number to help us comply with there requirements
If there is any addition comments please let us know
Should be Empty:

Customer Details: