Transportation - Client Eligibility Form

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Education, Medical and General Transportation Eligibility Form

Employment Transportation Assistance Program Eligibility Form

List Person Requesting Transportation Service

First Name

Middle Initial

Last Name

Address

Phone Number

Date of Birth

Emergency Contacts

Two people and/or agencies that we may contact in the event of an emergency.

Contact One

Name

Relationship to Applicant

Phone Number

Contact Two

Name

Relationship to Applicant

Phone Number

Additional Information

To make an accurate evaluation of your transportation needs and to make the service valuable to you, we need to know the following information.

Does the person requesting the service have a physical or mental impairment Value is not selected

Briefly describe the impairment.

Does the person requesting the service use any of the following? (Select all that apply.) Values are not selected

How will the person requesting the service typically travel? (Select all that apply.) Values are not selected

Will you need transportation to a daycare as part of your employment transportation? Value is not selected

Address of Daycare

Does someone need to be at home when transportation drops the person off at home? Value is not selected

What will be the purpose of the trip? (Select all that apply.) Values are not selected

Employment Information

Employer

Employer Address

Typical Work Schedule

Note: There may be a fare of $2.50 one-way for transportation. You will be notified if the fare applies. Collection of the fare is processed through a monthly billing process. Please pay the fare in a timely manner. Failure to pay could result in a suspension from the service.

To be eligible for Employment transportation services the following information must be provided.

Employment Verification Values are not selected

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Family Size

Other

Income Information

Total Gross Monthly Income

Information Verification

I certify that the above information, which my agency or I have provided, is true and correct. I understand that if this application is approved, I must abide by the rules and regulations set forth by the Guilford County Transportation and Mobility Services.

Signature of person requesting service or caregiver

Date

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Transportation - Client Eligibility Form

Select Language / Seleccione idioma

Select Form

List Person Requesting Transportation Service

Emergency Contacts

Additional Information

Employment Information

Income Information

Information Verification