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)

Preference for type/style of vehicle

Engine (Fuel) Preference

License Preferences

Length of vehicle

Which do you require

Delivery system equipment (compressor & vacuum) - check all that apply:

Which do you prefer

Other interior requirements

Estimated budget range

Are you planning to issue an RFP (request for proposal) to Vehicle Manufacturers

If yes, when?

Timeline: By when do you want to a acquire a vehicle

Status of funding

Are you applying for a grant?

If applying for a grant, when is grant application due

Date

If applying for a grant, who is the grantor

What is your anticipated grant amount range

When will grant be awarded

Date

Additional Questions or Comments

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