Membership Application Form

If you have any questions about this form please contact us. If you do not receive a reply within 24 hours please call us at (506) 466-4444.

First Name (required):

Last Name (required):

Mailing Address (required):

Town/Village (required):

Postal Code (required):

Civic Address (if different from Mailing Address):

Phone Number (required):

Email Address:

Number of children in your household under the age of 18 (if any):

Were you referred by someone?

 Yes No

If Yes, who referred you?

Do you own a vehicle?

 Yes No

Do you have a disability?

 Yes No

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?

 Yes No

**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?

 Yes No

**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)

 Yes No

Date (required)