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2. VERY IMPORTANT INFO (PLEASE READ BEFORE CONTINUING THIS FORM)

   This form is for initial setup (first time rider applicants) only.  Please do not keep submitting online forms continuously after you have submitted this form once.  You would need to call our office at 910-875-8696 to schedule future rides.

   For transportation requests to medical appointments, please read the following before submitting this form:  

   1.  If you receive Medicaid benefits, do not use this form.  Call Medicaid transportation at 910-878-4041 to schedule your ride.  

   2.  If you receive Managed Care benefits such as WellCare, United Health Care, etc., do not use this form.  Please schedule your ride with your provider.

   3.  If neither of the situations above applies to you, you may continue with this form.

4. First Name/Middle Initial*
5. Last Name*
7. SSN # (Last 4 #s)
8. Date of Birth*
   Date of Birth
9. Gender
   -- Select One --MaleFemale
11. Phone #*
12. Email*
14. Passenger Assistance Codes*

    1. Wheelchair
    2. Blind
    3. Car Seat
    4. Other

    (Choose all that apply)
15. Race/Ethnicity

    1. Caucasian
    2. African American
    3. Native American
    4. Latino/Hispanic
    5. Other
16. Language
    -- Select One --EnglishSpanish
18. Street Address*
20. Mailing Address*
22. City*
23. State*
24. Zip*
26. EMERGENCY CONTACT INFO
28. First Name*
29. Last Name*
31. Phone #*
32. Street Address, City, State
33. Relationship to Applicant
35. DAILY TRIP INFORMATION

    (Complete this section if you are seeking routine transportation.  All transportation requests must be submitted by 11am one business day prior to when you want to start.  All requests received after 11am will not be available for the next business day, but will be available for starting the following business day.)

37. Trip Type*
    -- Select One --One-wayRound-trip
38. Frequency*
    -- Select One --One time onlyMultiple days

    (If multiple days check "Days of Service")
39. Pickup Address*
40. Drop Off Address*
42. Days of Service (for subscription/routine rides only)

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday

    (Check all that apply)

43. Start Date*
    Start Date
44. Appointment Time*
    Appointment Time
45. Return Time (If requesting round trip)
    Return Time (If requesting round trip)
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field