* 1. I need transportation because: (Check all that apply.)

* 2. I need transportation to: (Check your top three choices.)

* 3. I need to go to: (Check your top three locations.)

* 4. I use the following means of transportation.

* 5. Please provide the address for your top 3 destinations. (Address or cross streets and city)

* 6. Do you use a mobility aid when you travel?

* 7. Below are features of transportation services. Please rate how important each feature is to you, using a number from 1-5, with 1 being not at all important and 5 being very important.

  Not at all important Very important
Service within your local community
Service beyond your local community
Service to out of county locations
Service to regional medical facilities
Daytime Service
Evening Service
Weekend Service
Help with doors or packages
Help getting to vehicle or getting in and out of vehicle
Wheelchair accessible vehicle

* 8. For mapping purposes, please provide your pickup location (cross streets and city)

* 9. If you would like us to contact you about transportation resources please tell us how to contact you.