Request Another Transportation Subscription

Guidelines for Submitting a Transportation Subscription Request Form

The online request form is only for door-to-door transportation subscription trips.
All online trip requests must be received by the Transportation Scheduling Unit at least three business days before the first trip.
Requests received after 2:00 pm on the third business day will not be accepted. The trip request form must be completed in its entirety.
Incomplete requests or requests not within the guidelines will not be accepted or confirmed.
For complete requests, a member of the Transportation Scheduling Unit will confirm the trip details and vendor selected by the end of the next business day following receipt of the faxed request.
When filling out the address portions of the form, please include the street number, name of the street, the suite or building number, city, and zip code. For example: 3627 Beatties Ford Road, Suite B, Charlotte, 28216
When filling out Wheel Chair Type– certain vendors are unable to accommodate certain types of wheel chair. So that we can select the right vendor, please tell us which type of wheel chair you have. For example: high back, extra large

The following requests cannot be made via the online form; instead they must be made by calling the Transportation Scheduling Unit: 704-336-4547.

Bus Pass requests
Cancellations
First-time riders
Group trips (trips consisting of 5 or more riders)
Non-medical trips
Demand trips (one time appointments)
Trips requiring multiple stops
Trips that require pre-authorization
Trips that require temporary exemptions
Veteran Trips

By submitting this form you are acknowledging that you are: not a first time rider, scheduling your appointment at least 3 business days in advance, your trip does not require pre-authorization, you do not have more than 3 additional riders, you are not requesting a bus pass, you do not have multiple stops, you are not making a trip change and/or cancellation and you have read the online trip request guidelines.

I certify that my request meets the above stated criteria.

On who's behalf are you submitting this request?

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Best time to reach you by phone between 7AM and 4PM?

Name

First NameLast Name

Date of birth

Date

Start date of your subscription

Please enter a valid phone number.Format: (000) 000-0000.

End date of your subscription

Date

Subscription Type:

Please select the days of the week and the times you need to be dropped off and picked up. (include AM or PM)

Rows	Dropped Off	Picked Up
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday

Please input the requested travel details below. Please be sure to include the apartment or suite number. ***If you need multiple stops, please call 704.336.4547***

Rows	Pick Up Location	Return Location
Street Address
Apt/Suite Number (or NA)
City
State
Zip Code
Phone Number

Destination Appointment Type:

Other (please describe)

Destination Facility Name:

Type a question

Rows	First Name	Last Name	Age	Car Seat / Booster Seat needed (Yes/No)?
Additional Rider 1 Info
Additional Rider 2 Info
Additional Rider 3 Info

Please indicate any special considerations (check all that apply).

Please be specific and provide any additional information or explanation that might be needed to handle your request.

Any person who knowingly and willingly makes any representation that is:

1) false to obtain information from the Department of Social Services records, and/or

2) intended to deceive the Department of Social Services as to the true identity of an individual could be punished by a fine or imprisonment, or both.

By submitting this form, I acknowledge that I have read and agree with the above statement.

Please enter your initials below:

Please verify that you are human

Request Another Transportation Subscription

Requester's Information:

Rider's Information:

Additional Riders:

Additional Information: