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ACCESSIBLE VEHICLE FOR ELDERLY AND DISABLED SPECIALIZED TRANSPORTATION

VENDOR APPLICATION

Agency Name:

Address:

City: State: Zip:

Website:

Contact Person: Title:

Phone:

Is the provider in the FACT transportation brokerage?

☐ Yes

No, but intends to join the brokerage if awarded vehicle/s.

______________________________________________________________________________

Describe your organization and your experience with providing transportation services. ________________________________________________________________________ What is your service area? Please attach maps on 8.5” x 11” sheet, if available.

Describe what types of senior (60 years of age or older) or disabled clients you serve?

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How many vehicles does your agency own? How many drivers do you employ or use on a volunteer basis?

Do you have maintenance facilities for your vehicles?

____________________________________________________________________________ Briefly explain your vehicle maintenance program, including pre- and post-trip inspections. Please attach any sample inspection and maintenance forms.

Briefly describe your agency’s driver training program (classroom/behind the wheel, sensitivity, emergency prep, first aid, CPR). Please attach any training manuals, course descriptions, etc.

How many vehicles would you be interested in receiving? How do you plan to use each vehicle? Please provide names of any participating agency(ies), vehicle usage (specify days and hours of use, service area, number of passengers served, ridesharing, etc. proposed to offer for FACT and your agency’s clients).

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______________________________________________________________________________

If awarded a vehicle, how many estimated one-way trips per year will be provided for FACT

clients using the vehicle?

Note: Do not count a rider in more than one category.

One-way passenger trips provided to Person with Disabilities

One-way passenger trips provided to Seniors/Elderly Individuals

One-way passenger trips for wheelchair lift users

TOTAL

______________________________________________________________________________ If awarded a vehicle, how many estimated one-way trips per year will be provided for your

agency’s other (non-FACT) clients using the vehicle?

One-way passenger trips provided to Person with Disabilities

One-way passenger trips provided to Seniors/Elderly Individuals

One-way passenger trips for wheelchair lift users

TOTAL

*Cost per one-way passenger trip (estimated number of trips divided by estimated value of vehicle) will

be considered a fully loaded cost, inclusive of all maintenance, fuel, drivers/staff, registration, insurance,

and other expenses needed to operate vehicle/s and provide trips.

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CERTIFICATION

I certify that, to the best of my knowledge, the information in this application is true and

accurate and that ____________________________ has the necessary financial and managerial

capability to adequately operate, maintain, and insure the vehicle for which this application is

being made.

I also acknowledge that I have read and understand the requirements towards fulfilling the

remaining useful life of the vehicle if selected for award including, but not limited to:

operations contracting and reporting.

PLEASE PRINT AND SIGN

_____________________________________

Executive Director/President/CEO

(or person authorized to submit this application and enter into an agreement)

_____________________________________ _____________

Print Name Date

____________________

Taxpayer ID No.

Please e-mail completed application to:

operez@factsd.org

(Agency Name)