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?

    YesNo

    If Yes, who referred you?

    Do you own a vehicle?

    YesNo

    Do you have a disability?

    YesNo

    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?

    YesNo

    **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?

    YesNo

    **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?

    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):

    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)

    YesNo

    Date (required)