Step 1: General Information Required fields marked with *

Name (first and last):*

Address

Address 2

City

State

Zip

Country

Phone*

Fax

Email*

Other

Step 2: Vehicle Information:

What is the main purpose for this unit?

Briefly describe the population you are serving.

Briefly describe the geography that you will be serving.

Vehicle Style

Cut-Away Van
Van/Coach/RV (30+ feet)
Air-ride suspension
Air Brakes

Truck
Bus
Trailer

Engine Location

Front Rear

Number of on-board staff.

Do intended drivers have a CDL/chauffeurs' license?

Yes No

If not, will they be willing to obtain one?

Yes No

Step 3: Interior Layout

Exam Rooms:
Laboratory:	Yes No
Pharmacy/Dispensary:	Yes No
Waiting/Reception Area:	Yes No
Consultation Room: How many?	Yes No
Changing Rooms: How many?	Yes No
Kitchen:	Yes No
Bathroom:	None Regular Handicap

Telecommunications Hookups:

(For telephones and computers)

Yes No

What equipment will you need in these rooms?

Step 4: Exterior Layout

Exterior Doors:
Please describe the locations for these doors.
Slideouts:
Under Vehicle Storage:	Yes No

Central A/C:

None Single zone Multi-zone

Security System:	Yes No
Auto Leveling System:	Yes No

Wheelchair Lift:

None
Under Body Lift
From Interior
Rear Location
Standard Side Lift

Special Graphics or Logos on the Exterior:

(Please describe)

Step 5: Miscellaneous and Budget

Vehicle Engine Type:

No Preference
Diesel
Gasoline

On Board Power Generators:

Yes No

Funding Available:

Yes
Currently Fundraising

Budget Amount:

Interested in a Lease To Own:

Yes No

Will K&D Coaches Need to Procure Medical Equipent:

Yes No

If Yes, Is There A Preferred Provider?

Other Comments:

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Step 1: General Information Required fields marked with *

Step 2: Vehicle Information:

Step 3: Interior Layout

Step 4: Exterior Layout

Step 5: Miscellaneous and Budget

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