Sidewinder Van Conversions - Feedback Form Sidewinder Van Conversions Please complete this feedback form, we will use this form to respond to your inquiry about your van conversion needs. Your First Name Your Last Name Your Company Department Name Mailing Address (Street, City, State/Province, Country, Zip/Postal Code) Telephone Number (Area Code) Fax Number (Area Code) Company E-mail Address My E-mail Address I am interested in the following options: Power Tri-fold sofa bed  Power slides on rear sofa bed  Leather Seating Package  Six way power driver's seat  Six way power passenger's seat  TV sport fiberglass raised roof  Any Gaming console i.e. Xbox 360, Playstation 2 etc. 5 Piece Simulated Woodgrain Dash Kit Pop-Down Radar Detector and Overhead Console 13" and up Flat plasma/LCD T.V./DVD Player 12-Disc CD changer Manual Piston Tri-Fold  Fiberglass Running Boards, Step/Tread and Trim Moulding Upgraded Stereo Systems  Satellite Radio Satellite Phone/GPS System Please select these other options: Mojave Palm Springs Weekender Do you require adaptive/mobility equipment?: (i.e. Hand Controls, Wheelchair Lifts, etc.)  Yes  No Privacy Statement We value your privacy, and recognize that no one should complete any form requesting personal information without a statement of intent. The information gathered from this form is for the internal use of Sidewinder Van Conversions, and will not be sold, traded or otherwise given to any outside agency, in whole, or in part, for any reason. The purpose of the form is to provide rapid exchange of information only.     Return to Sidewinder Van Conversions Home Page | sales@sidewinder-conversions.com

Sidewinder Conversions and Mobility 44658 Yale Road West,  Chilliwack, BC, Canada V2R 0G5 TEL: (604) 792-2082  Fax: (604) 792-8920