Nextek™
Customer Profile Questionnaire
Nextek's PAWS Technology Power Wheelchairs are currently in clinical testing. Nextek's plan is to begin producing and offering PAWS Chairs for sale to users by 2004. By filling out and submitting this questionnaire to Nextek, prospective PAWS users will have the opportunity to be among the first to get delivery of an advanced Nextek PAWS Wheelchair.

The names of questionnaire respondents will be placed in a queue in the order of receipt and will receive options to acquire PAWS Wheelchairs in that order when commercial production begins.

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Contact Information

* Required Items

First Name

Last Name

Business Name

Street Address

Unit#

City

State/Province

Country

Zip Code

Email Address

Yes .|. No

Would you like to receive Nextek email news releases on the development and availability of PAWS Technology Wheelchairs?

 

What is your primary operating environment? (Choose One)
 Indoor — home, shopping, workplace
Outdoor — sidewalks, streets & other ADA Accessible areas
 Outdoor — rugged & steep areas

Do you require special seating/accessories? (Choose One)
 No
 Yes. If yes, describe.

What is your weight? .......... What is your age?

What make and model of power wheelchair do you currently use?

How long have you used your current wheelchair?
years months
How do you operate your wheelchair? (Choose One)
 Joystick
 Sip & puff
 Head control
 Other. Describe:


When do you expect to replace your current wheelchair?
 years months
What improved features and performance do you expect to gain in upgrading to the Nextek PAWS Technology?


At this time, which PAWS Model would you be inclined to consider acquiring?
 2 wheel drive - indoor/outdoor ADA accessible terrain
 4 wheel drive - indoor/outdoor snow, ice, sand & rough, sloped terrain

Are you employed?
Yes................. No
 Full time........... Part time
How will you purchase a new power wheelchair? (Check all that apply)
 Medicare
 VA
 Private insurance
 Personal sources

Please take a moment to check your questionaire.

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Nextek Mobility Corporation is developing a power wheelchair technology unlike any the world has ever seen, with capabilities beyond those previously experienced. In 1995 Nextek Mobility was incorporated in the sunny state of New Mexico. While additional prototypes were built and patents applied for, the search for capital became a focus. In 1998 Nextek was awarded a Phase I SBIR from the National Institutes of Health. (1R43HD34643-01A) With chairs lined up for trials in hospitals throughout Albuquerque, NM, the ten-year dream technology —a top-rated, life-enhancing, fully functional parallel all-wheel steering power chair—is closer than ever to being realized. Tour the site to see how far the PAWS chair has advanced. PAWS is “Parallel All Wheel Steering”— Nextek Mobility Corporation’s new power wheelchair technology. It is called PAWS because the seat and all of the wheels share a common linkage that allows them to rotate relative to the frame but maintains them parallel to one another. This unique configuration has many advantages. The PAWS technology provides the wheelchair user with the ultimate combination of maneuverability and stabilityfor both indoor and outdoor use.