Target Area Candidate Statements - Fresno Economic Opportunities Commission

E-mail address*

Service Coordinator Name*

Effective Date*

Vendor Number*

POS in Sandis (Select "No" if you don't use Sandis)*

Yes
No

UCI # (Client ID)*

Days of the week for transportation (Select All)*

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Client Name*

Client Date of Birth*

Client Age*

Client Mobility*

Ambulatory
Wheel Chair Bound
Other

Client Mobility - If Other, please explain here:

Client Home contact information*

Client Primary speaking language*

Client Special Requirements (Select All That Apply)*

Blind
Mute/Non Verbal
Deaf
Seatbelt assistance
None
Other

Client Special Requirements - If Other, please explain here:

Pickup Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Adult needs to receive client when dropped off at home*

Yes
No

Drop off (Destination) Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

I will submit a Transportation Service Request (TSR).*

Yes
No

I will e-mail a Purchase Order of Service (POS).*

Yes
No

CAPTCHA

2020 Target Area
Candidate Statements

Target Area A

Target Area D

Target Area E

Target Area G

Target Area A Candidate Statements

Target Area D Candidate Statements

Target Area E Candidate Statements

Target Area G Candidate Statements

2020 Target AreaCandidate Statements