Form 5263 - License Office Location Assessment
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FORM
MISSOURI DEPARTMENT OF REVENUE
5263
LICENSE OFFICES BUREAU
LICENSE OFFICE LOCATION ASSESSMENT
(REV. 09-2012)
OFFICE NAME
o
Current Location
o
New Location
PROPOSED ADDRESS
COMPLETED BY
DATE (MM/DD/YYYY)
THE FOLLOWING INFORMATION MUST BE COMPLETED BY FIELD COORDINATOR
For any zeros, please explain in remarks.
Ratings:
0
1
2
3
LOCATION
• Is location easy to find?
o
o
o
o
0
1
2
3
• Is location easily accessible from main roads?
o
o
o
o
0
1
2
3
• Is location within the city limits or does it meet
any restrictions listed below?
o
Yes
o
No
(If no, explain in remarks).
Restrictions noted in RFP, if any:
BUILDING
o
o
o
o
• Is building suitable as a public building/license office?
0
1
2
3
• Is building easily accessible for elderly/disabled?
o
o
o
o
0
1
2
3
• If there are steps to the entrance, is there also a ramp?
o
Yes
o
No
• If not ground level, is there an elevator?
o
Yes
o
No
o
N/A
PARKING
• Is there ample parking within close proximity to building?
o
o
o
o
0
1
2
3
• Is surface level?
o
o
o
o
0
1
2
3
• Is parking in a lot (verses off-street)?
o
Yes
o
No
• Is parking free?
o
Yes
o
No
Public Restroom?
o
Yes
o
No
Are there any safety/other concerns with the location or building?
o
Yes
o
No
If yes, please explain in remarks.
REMARKS:
If this assessment is not for the current location, rate the proposed location against the current location:
o Not as good (Explain above)
o Equal to
o Better Than (Explain above)
SIGNATURE OF FIELD COORDINATOR
DATE (MM/DD/YYYY)
DOR-5263 (09-2012)
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