Fillable 10716 Ultrasound Application

Fill Online, Printable, Fillable, Blank 10716 Ultrasound Application Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

10716 Ultrasound Application

On average this form takes 23 minutes to complete

The 10716 Ultrasound Application form is 4 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 88 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
ULTRASOUND
PROGRAM
APPLICATION
GENERAL INFORMATION
Please indicate which matching funds program option being applied for:
_____ Ultrasound Machine Funding
_____ Ultrasound Machine and Vehicle Funding for Mobile Unit
Sponsoring state/provincial or local council: __________________________________________ Number: _________
Council location: _________________________ State/Province ________ e council voted to approve proceeding
with fundraising for this program on (date): ____________________
Contact Person: _______________________________ Title: _____________________ Date: ________________
Telephone #: ________________ Address: _________________________________________________________
Pregnancy Center: _______________________________________ Telephone: _____________________________
Contact Person: ______________________________ Title: ________________ Email: _____________________
Address: ____________________________ City/Town: ___________ State/Province: _______ Zip Code: ________
U.S. – Tax Status: ____ 501(c)(3) ____ Other: _________________ PCC’s U.S. Tax ID # (EIN): ________________
Canada – e Canadian Revenue Agency (CRA) has approved this PCC as a registered charity authorized to
perform limited medical services: (circle) Yes No Canadian Registered Charity #:______________
National Affiliations: (circle) NIFLA Care Net Heartbeat other: ____________________________________
( _____ ) is pregnancy center has no policies that are anti-Catholic in any way and does not engage in practices that
would tend to lead Catholic women away from their faith.
( _____ ) is pregnancy center does not advocate or refer for birth control.
Does the pregnancy center require ( ________ ) employees, ( ________ ) volunteers or ( ________ ) patients/clients
to sign a Statement of Faith?
Yes ____ (If yes, please enclose a copy.) No _____
LIFE
FAITH IN ACTION
FAITH IN ACTION
LIFE
ULTRASOUND MACHINE FUNDING
Please verify each of the following statements and indicate with a checkmark:
_____ e center complies with all state/provincial/local laws/regulations to operate an ultrasound machine.
_____ e pregnancy center’s medical director is: Dr. _______________________________________
Address: ___________________________________
_____ e machine will be staffed with trained, licensed, and experienced medical personnel.
_____ e pregnancy center will offer limited diagnostic medical services, not non-diagnostic/entertainment services.
_____ e center has adequate insurance for operation of the ultrasound machine.
Ultrasound Machine Manufacturer: ___________________________ Model: ______________________________
Type of ultrasound machine to be purchased: 2D ____ 3D ____ 4D ____ other ___________________________
List price: $________________________ Check: ____ new ____ refurbished ____ portable
Machine’s actual cost (not including freight, taxes, training, salaries, etc.): $__________________________
Please list the council number of any other councils which assisted in or contributed to the state council’s/ council’s
fundraising efforts. # ______________ # ______________ # _______________ # ______________
Briey describe anything particularly noteworthy about the pregnancy center (near abortion clinic, colleges, military
base, etc.) and the major fund raising programs used by your council (use additional paper if needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Total amount raised to date by the council (must be at least 50% of the machine’s actual cost): $ _________________
FAITH IN ACTION
LIFE
VEHICLE FUNDING FOR MOBILE UNIT
(If not applicable, skip to next section)
Vehicle type: (circle one) Bus RV Truck Van other: ________________________________
Vehicle Manufacturer: _________________________ Model/Year: ________________________________
(circle one) Purchased: New Used Leased Donated other: _______________________________
Obtained from: (circle one) Manufacturer/Dealership ICU Mobile Save the Storks
Private Seller other: __________________________
Original list price of vehicle/mobile unit: $_________________________
Actual purchase price (aer discount, if any) of vehicle (not including registration, fees, taxes, driver costs, maintenance,
fuel, etc.): $_________________________
Does vehicle come fully equipped to offer ultrasound services? (Circle) Yes No
If no, describe conversion work done/to be done: ______________________________________________________
____________________________________________________________________________________________
Total estimated/actual costs to convert vehicle to mobile medical unit: $ ______________
Total mobile unit costs (vehicle + conversion expenses, if any): $ ______________
Has the council completed fundraising to cover the full cost of purchase/purchase and conversion of the vehicle/mobile
unit? (Circle) Yes No
If yes, what is the total amount of funds raised by the council? (Council funds raised + expected Supreme Council grant,
must equal or exceed the total cost of purchase/purchase and conversion expenses for the mobile unit, including the cost of the
ultrasound machine) $ ________________________
Please verify each of the following statements and indicate with a checkmark:
_____ e mobile unit complies with all state/provincial/local laws/regulations regarding registration/operation of a
mobile medical unit. e vehicle will park on private property and/or t in intended public parking spaces in
compliance with local zoning and parking laws and permitting processes.
_____ If required, the pregnancy center will seek certication of the mobile unit by health/housing authority inspection.
_____ e mobile unit will be driven by licensed, experienced, insured drivers.
_____ e mobile unit has adequate motor vehicle insurance.
Briey describe anything particularly noteworthy about the mobile unit, including how/where it will be used (use
additional paper if needed): _______________________________________________________________________
___________________________________________________________________________________________
FAITH IN ACTION
LIFE
10716 6/18
GRANT AMOUNTS
A. Ultrasound Machine (50% of the actual cost of the machine): $ ________________
B. Mobile unit (if applicable):
(e lesser of: the purchase price of the vehicle, plus conversion
expenses (if any), or, 50% of the actual cost of the machine): $ ________________
Total grant amount (Lines A + B) requested from Supreme Council Office: $ ________________
Please make the Supreme Council’s check for matching funds payable to: ___ the pregnancy center listed above; or,
___ (State Council Charity) ____________________________________ EIN/Charity #____________________
Please mail check to (name/address): ________________________________________________________________
____________________________________________________________________________________________
State Deputy’s signature: ________________________________________ Date: __________________________
Email a copy of this document to: fraternalmission@kofc.org
(Councils should also retain a copy of this completed form for their les)
Enclosures:
1. Ultrasound Machine Price Quote
2. Vehicle Price Quote (if applicable)
3. Documentation for estimated/actual costs of conversion expenses (if any)
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

10716 Ultrasound Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document