Request edit access
Census Kiosk Partner Location Application
Please provide the following information to apply to host a census kiosk. Find more information at [website] and reach out to [email address] with any questions.
Email address *
Name of your organization
Your answer
Type of organization
Name of your organization's main point of contact for this effort
Your answer
Email address of main point of contact
Your answer
Phone number of main point of contact
Your answer
Name of facility/location where kiosk will be located
Your answer
Address of facility/location where kiosk will be located
Your answer
Owning entity
Your answer
Does this location meet the requirements for supporting a census kiosk? [list requirements]
Hours of operation
Your answer
Will this location have staff available to assist the public?
Hours of staff availability
Your answer
Site phone number
Your answer
Language support available at location (select all that apply)
Number of devices available
Your answer
Computer type (desktop, laptop, tablet) and number of each
Your answer
Can a phone land line be made available?
Does this location have a public facing counter?
Is this location ADA accessible? (see: https://www.ada.gov/2010ADAstandards_index.htm)
Building type
Describe parking and transportation availability for the public
Your answer
Notes
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Next Century Cities. Report Abuse