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):

    Civic Address (if different from Mailing Address):

    Telephone (required):

    Cell Phone:

    Other:

    Email Address:

    Date of Birth:

    Number of children in household:

    Names & Date of Birth of Children:

    How did you hear about our service?

    Do you own a vehicle?
    YesNo

    Do you have a disability?
    YesNo

    Do you require the use of a wheelchair accessible vehicle?
    YesNo

    Do you have an attendant that will be traveling with you?
    YesNo

    If yes, please note that attendants travel for half 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.

    Please describe any assistance that you might require in order to use our service:

    What will be your main purpose for using our service?
    MedicalEmploymentJob Training/EducationHousehold ErrandsFamilySocial or RecreationalOther

    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):

    Relationship to member:

    Telephone:

    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)

    YesNo

    Date (required)