Please provide our Mobility Information Specialist the following information so he/she can determine what services are best suited to meet your needs:

Once received a representative will review and contact you to discuss possible options.

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* 1. Please provide our Mobility Information Specialist the following information so he/she can determine what services are best suited to meet your needs:

Once received a representative will review and contact you to discuss possible options.

Are you 60 years of age or older?

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* 2. Are you 60 years of age or older?

Do you have a disability?

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* 3. Do you have a disability?

If you are disabled does your disability prohibit you from using public transportation?

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* 4. If you are disabled does your disability prohibit you from using public transportation?

Are you receiving TANF (Temporary Assistance for Needing Families) Cash or are you part of a low-income family with dependent children?

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* 5. Are you receiving TANF (Temporary Assistance for Needing Families) Cash or are you part of a low-income family with dependent children?

Please check the purpose of your transportation needs? (Check all that apply)

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* 6. Please check the purpose of your transportation needs? (Check all that apply)

Please provide the starting address of your trip?

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* 7. Please provide the starting address of your trip?

Please provide destination address?

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* 8. Please provide destination address?

What days per week would you require this ride? (Check all that apply)

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* 9. What days per week would you require this ride? (Check all that apply)

Please provide us with the time(s) you would need this trip and any other pertinent information?

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* 10. Please provide us with the time(s) you would need this trip and any other pertinent information?

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