General Application PIKE COUNTY TRANSPORTATION SHARED RIDE APPLICATION FORM

PIKE COUNTY TRANSPORTATION GENERAL APPLICATION FORM

For Any Resident Applying for Services
SECTION A: APPLICANT INFORMATION
Full Name *

First NameLast Name
Date of Birth *

MonthDayYear
Date
Social Security Number:*
Must include to check for dual eligibility
Physical Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Is your Mailing Address different from your Physical Address? *
Mailing Address *

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you have State Insurance? *
Includes Medicaid, Medicare, ACCESS Medical
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Transportation Program

You must provide a copy of Proof of age

Acceptable Proof of Age Documents

Please provide one of the following documents that includes your date of birth:
· Armed Forces Discharge Papers
· Birth Certificate
· Enhanced Tribal Card or Native American Tribal Photo Identification Card
· EVS Printout (MATP)
· Form I-94 - Immigration Record from Customs and Border Protection
· Naturalization Papers
· PACE Identification Card
· Passport
· Pennsylvania Department of Corrections Inmate Identification Card
· Resident Alien Card
· Statement of Age (issued by the Railroad Retirement Board)
· Statement of Age (issued by the U.S. Social Security Administration)
· State-Issued Photo ID Card
· U.S. Department of Defense ID
· U.S. Driver’s License
· Veteran Health ID Card

Ensure your document is current and clearly displays your date of birth to verify eligibility. For more information or assistance, please contact our support team.
Upload proof of age:*

Cancelof
SECTION B: TRANSPORTATION NEEDS
Do you require an escort to travel with you?*
If yes, explain reason:*
Traveling in a Wheelchair? *
Please provide directions to your home: (Include: side of the street, color of house and landmarks)*
SECTION C: ACKNOWLEDGEMENTS & CONSENT
By signing below, I confirm that I am a resident of Pike County, PA; understand that trips must be reserved by 12pm noon, one business day in advance; acknowledge that some trip purposes may not be eligible for subsidized fare; authorize Pike County Transportation to verify my eligibility and refer me to other programs if applicable; and understand that a co-payment is required for each ride as outlined by program rules.*
Should be Empty:

PIKE COUNTY TRANSPORTATION GENERAL APPLICATION FORM

SECTION A: APPLICANT INFORMATION

SECTION B: TRANSPORTATION NEEDS

SECTION C: ACKNOWLEDGEMENTS & CONSENT