Step 1 of 3 33% Vehicle InformationPlease enter the details of your curent vehicle. If you do not currently own a vehicle, you may leave this section blank.Vehicle Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992Vehicle MakeExample: Chrysler Vehicle ModelExample: Town & Country Mobility Device InformationPlease enter the details of your mobility scooter or power wheelchair. If you do not know this information or do not currently own a mobility device, you may leave this section blank. We will be happy to assist you in identifying your mobility device or selecting one that will meet your needs.Mobility Device ManufacturerExamples: Pride, Golden Technolgies Mobility Device ModelExamples: Victory 10, Companion 340 Contact InformationPlease provide either an email address or phone number so a Mobility Consultant can follow up with you.Name* First Last Preferred Contact Method*How would you like us to follow up with you? Select All Phone Text Message Email Email Address* Phone Number*Preferred LocationPlease select your preferred Creative Mobility Group location.Detroit - East (Madison Heights)Detroit - West (Wayne)Flint (Flint Township)Grand Rapids (Byron Center)View our Privacy Policy I agree to receive product information and promotions from the Creative Mobility Group.View our Privacy Policy
