Dealer Order Form

Welcome to Triumph Mobility’s on line ordering for existing dealers. Please complete all form fields. Once the order has been received we will send you an order confirmation for verification before the order ships.

Bill To:
Ship To:
Model Number Description Quantity
500-10191 Escape - Charcoal - Super low (19" Seat height)
500-10211 Escape - Charcoal - Low (21" Seat height)
500-10241 Escape - Charcoal - Standard (24" Seat height)
500-10195 Escape - Red - Super low (19" Seat height)
500-10215 Escape - Red - Low (21" Seat height)
500-10245 Escape - Red - Standard (24" Seat height)
500-10192 Escape - Blue - Super Low (19" Seat height)
500-10212 Escape - Blue - Low (21" Seat height)
500-10242 Escape - Blue - Standard (24" Seat height)
Escape Mini
500-20203 Escape Mini - Orange - Low (20" Seat height - No shopping bag)
Escape Accesories
500-3000 Escape Shopping Bag
500-4000 Escape Slow Down Brakes (Set)
500-4100 Escape Cane Holder
500-4200 Escape Cup Holder
500-4300 Escape Tray
500-4400 Escape Accessories Pack (cane holder, cup holder, & tray)
Rollz Motion
2010RM0010 Rollz Motion2 Pebble White Complete - REGULAR
2010RM0011 Rollz Motion2 Island Blue Complete - REGULAR
2010RM0012 Rollz Motion2 Black Complete - REGULAR
2010RM0013 Rollz Motion2 Dark Purple Complete - REGULAR
2011RM0011 Rollz Motion2 Island Blue Complete - SMALL
2011RM0012 Rollz Motion2 Matt Black Complete - SMALL
2010RM0014 Rollz Motion Performance - Jungle Green - REGULAR
Rollz Motion Accessories
1020RM0002 Rollz Motion Cup Holder
1020RM0004 Rollz Motion Premium Shopping Bag
1020RM0010 Rollz Motion Travel Cover
1020RM0012 Rollz Motion Back Support
1020RM0018 Rollz Motion Seat Belt
1020RM0019 Rollz Motion Umbrella
1020RM0021 Rollz Motion Slow Down Brake
1020RM0013 Rollz Motion Touch Up Pen - Pebble White
1020RM0014 Rollz Motion Touch Up Pen - Island Blue
1020RM0015 Rollz Motion Touch Up Pen - Matt Black
1020RM0016 Rollz Motion Touch Up Pen - Dark Purple
2030RM0049 Rollz Motion 3 in 1 Cane, Chair Pack & Bag Holder
Rollz Flex
3010RF0003 Rollz Flex White - Bright Purple Bag & Black Seat - REGULAR
3010RF0004 Rollz Flex White - Denim Grey Bag & Tan Seat - REGULAR
3011RF0001 Rollz Flex White - Bright Purple Bag & Black Seat - SMALL
3011RF0002 Rollz Flex white - Denim Grey Bag & Tan Seat - SMALL
Rollz Flex Accessories
3020RF0003 Rollz Flex Cane Holder
3020RF0005 Rollz Flex Touch Up Paint - White