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2. 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 #*
13. Passenger Assistance Codes*

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

    (Choose all that apply)
14. Race/Ethnicity

    1. Caucasian
    2. African American
    3. Native American
    4. Latino/Hispanic
    5. Other
15. Language
    -- Select One --EnglishSpanish
17. Street Address*
19. Mailing Address*
21. City*
22. State*
23. Zip*
25. EMERGENCY CONTACT INFO
27. First Name*
28. Last Name*
30. Phone #*
31. Street Address, City, State
32. Relationship to Applicant
34. 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.)

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

    (If multiple days check "Days of Service")
38. Pickup Address*
39. Drop Off Address*
41. Days of Service

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

    (Check all that apply)
42. Start Date*
    Start Date
43. Appointment Time*
    Appointment Time
44. Pickup/Return Time (If applicable)
    Pickup/Return Time (If applicable)
Leave This Blank:


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

    This field is not part of the form submission.

48. Submit

* indicates a required field