FAITH IN ACTION
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 (aer 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 certication 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.
Briey describe anything particularly noteworthy about the mobile unit, including how/where it will be used (use
additional paper if needed): _______________________________________________________________________