Dental Vehicles Form Submission

Organization Name*
City*
State*
Entity*
Contact Name*
Contact Title*
Phone Number/Work*
Format: (000) 000 - 0000.
Phone Number/Mobile*
Format: (000) 000 - 0000.
Email*
Do you have an existing mobile outreach program *
Describe services currently, or planning to be provided (i.e., screenings, cleaning, sealants, cleaning, restorative, hygiene/education)*
Describe population to be served (i.e., children, seniors, all ages, underserved, occupational, etc) *
Where do you intend to serve *
Average miles/day mobile clinic will travel (RT) *
Motorcoach (Class A)Bus (Class A)No PreferenceTruckVan (Class B or C)Tow Trailer/5th Wheel
Engine (Fuel) Preference *
License Preferences *
Under 30'L (Class B or C)30-35'LUnder 30'L (Sprinter Type)36-40'L40'+LNo Preference
1-Operatory2-Operatories3-Operatories
Prefer equipment be purchased and installed by vendorPrefer to use portable equipmentI have my own equipment
Open BayPrivate Room(s)
Lab/Sterilization AreaIntake/Reception AreaWaiting/Education AreaBathroomWheelchair RampWheelchair LiftSlide-Out
Estimated budget range*
Timeline: By when do you want to a acquire a vehicle*
Status of funding*
YesNo
If you are applying for a grant, when is grant application due

MonthDayYear
Date
If applying for a grant, who is the grantor
What is your anticipated grant amount range
When will grant be awarded

MonthDayYear
Date
Additional Questions or Comments
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