Jesse Lee UMC - ASP Project
2009 Wheelchair Ramp Application Form
Contact Name:
Daytime Phone:
Evening Phone:
Mobile Phone:
Email:
Fax Number:
Organization (if applicable):
Is this a non-profit organization?
Non-Profit
Yes
No
If this wheelchair ramp is for an individual, is that person disabled?
Person Disabled?
Yes
No
Do you have access to a truck or large van?
Access_to_Truck
Yes
No
I can pick up the ramps at Jesse Lee Memorial United Methodist Church in Ridgefield, CT on:
Pick_Up_Times
Saturday, May 16, 2:00 PM
Sunday, May 17, 4:00 PM
Acknowledge
I Acknowledge That These Ramps Are For Use By A Non-Profit Organization Or For A Disabled Person.
I will need the following number of wheelchair ramp sections (see the Wheelchair Ramp Guidance and Prefab Wheelchair Panels documnets for details):
Panel A Ramps:
Choose Option
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Panel B Landing/Turnaround:
Choose Option
1
2
3
4
5
Panel C (5x8 Landing):
Choose Option
1
2
3
4
5
Applications must be submitted by May 15, 2009. If your application is accepted we will contact you.
Joomla Professional Work