*
Required Field
Organization Name
*
City
*
State
*
Entity
*
Non Profit
For Profit
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
*
Yes
No
Describe services currently, or planning to be provided (i.e., primary care, preventive screenings, immunization, behavioral health, HIV/AIDS testing)
*
Describe population to be served (i.e., children, seniors, all ages, underserved, occupational, etc)
*
Where do you intend to serve
*
Rural
Urban
Rural & Urban
Average miles/day mobile clinic will travel
*
Preference for type/style of vehicle
*
Motorcoach (Class A)
Bus (Class A)
Truck
Van (Class B orC) (Sprinter-type van)
Tow/Trailer (Cargo, ToyHauler, 5th Wheel)
No Preference
Engine (Fuel) Preference
*
Gas
Diesel
No Preference
License Preferences
*
CDL
Non CDL
No Preference
Preferred length of vehicle
*
Under 30'L Van (Class B or C)
30-35'L
36-40'L
40+L
No Preference
Will you require
*
1-Exam Room
2-Exam Rooms
Consult Room (behavioral health)
Multi-Purpose Room (testing, vaccination, school immunization, blood draw, etc.)
Lab Area
Intake/Reception Area
Waiting/Education Area
Bathroom
Wheelchair Lift
Wheelchair Ramp
Slide-Out
Are you planning to issue an RFP (request for proposal) to Vehicle Manufacturers
Please Select
Yes
No
Already Issued
Are you planning to issue an RFP (request for proposal) to Vehicle Manufacturers
Yes
No
Already Issued
Are you planning to issue an RFP (request for proposal) to Vehicle Manufacturers
*
Yes
No
Already Issued
If yes, when?
By when do you want to acquire a vehicle
*
Estimated budget range
*
Status of funding
*
Purchasing funds now available
Need assistance with financing
Applying for a grant
Are you applying for a grant?
*
Please Select
Yes
No
If applying for a grant, when is grant application due
-
Month
-
Day
Year
Date
If applying for a grant, who is the grantor
What is your anticipated grant amount range
When will grant be awarded
-
Month
-
Day
Year
Date
Additional Questions or Comments
PRINT THIS COMPLETED FORM FOR YOUR RECORDS BEFORE SUBMITTING
Type a question
Submit
Print Form
Should be Empty: