If you have any questions about this form please contact us. If you do not receive a reply within 36 hours please call us at (506) 466-4444.
First Name (required):
Last Name (required):
Mailing Address (required):
Postal Code (required):
Civic Address (if different from Mailing Address):
Phone Number (required):
Number of children in your household under the age of 18 (if any):
Were you referred by someone?
If Yes, who referred you?
Do you own a vehicle?
Do you have a disability?
If yes, please describe in detail the nature of your disability and any assistance that you might require because of your disability:
Are you 65 years or older?
**Veterans, please note; we are an approved provider for the Veterans Independence Program and you may qualify for a program to help with the costs of your drivers**
Do you required the use of a wheelchair accessible vehicle?
**If Yes, please not that attendants travel for A1/2 fare. It is the responsibility of the member to provide the attendant, and the attendant must be present at the time of the pick-up and return**
What will be your main purpose for using our service?
Medical Employment Job Training/Education Household Errands Family Social or Recreational Other
If Other, please describe:
Please list one person as a reference (required):
Phone number of reference (required):
Please provide the name of your emergency contact (required):
What is your relation to your emergency contact?
What is the phone number of your emergency contact?
I have read the rules and regulations set forth by the Charlotte County Alternative Transportation Association and I agree to abide by these rules and regulations. I declare that I do not have access to affordable and/or accessible transportation (required)
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