Address Line 1:
Address Line 2:
Date of Birth:
If there are children at your residence,
please provide their names.
Do you receive any DSS assistance?
If yes, please explain:
Do you have Medicaid?
Do you have a disability?
If yes, please explain.
Do you use any type of mobility device?
If yes, please choose all that apply.
Are you a veteran?
Do you need an attendant when you travel?
If yes please provide their name:
Any Mobility Device?
If you require an attendant when traveling, you will be responsible for providing one. The attendant will be picked up at the same addresses the passenger is traveling from.
Purpose of Transportation. (Please choose all that apply)
Name and Address of Job. (Needed for Work Transportation)
Times Needed for Transportation. (Please specify)
Any additional information you would like to add:
This form is not for the use of scheduling or cancelling transportation.
You will need to contact the office at:
(910) 346-2998 between 8:00 am and 5:00 pm.