Purchasing a Pre-Owned Mobile Clinic or Requesting a Quote for a Brand New Buildout ~ complete and submit the following Questionnaire.
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
*
Describe population to be served (i.e., children, seniors, all ages, underserved, occupational, etc)
*
Do you have an existing mobile outreach program?
*
Yes
No
Where do you intend to serve
*
Rural
Urban
Rural & Urban
Average miles/day mobile clinic will travel (RT)
*
Preference for type/style of vehicle
*
Motorcoach (Class A)
Bus (Class A)
No Preference
Truck
Van (Class B or C)
Tow Trailer/5th Wheel
Engine (Fuel) Preference
*
Gas
Diesel
No Preference
License Preferences
*
CDL
Non CDL
No Preference
Preferred length of vehicle
*
Under 30'L (Class B or C)
30-35'L
Under 30'L (Sprinter Type)
36-40'L
40'+L
No Preference
Number of testing booths
*
Number of stations per booth
*
Will you require
*
Consult Room
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
*
Yes
No
Already Issued
If yes, when?
Timeline: By when do you want to a 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
*
Yes
No
If applying for a grant, when is grant application due
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit year
Date
Additional Questions or Comments
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