2. Contact Information
4. First Name
5. Last Name
7. Address, City, State, Zip Code
9. Date of birth
10. Phone
11. E-mail address
13. Employer
14. Phone
16. Emergency contact
17. Phone
19. Please explain what access to a vehicle, if any, exists in your household
20. Describe any disability that keeps you from driving
22. Use this method for electronic submission.

    1. By checking this box, I declare that I meet the eligibility requirement for Town transportation services.

    Be sure all fields are fully filled out, or your application will not be immediately processed. 

24. Use this method for hard copy submission.

    By signing below, I declare that I meet the eligibility requirements for Town transportation services. 

26. Signature
27. Date
29. Parent or guardian signature if applicant is 16 or 17
31. This application is for the taxi program only. For Senior Center application, call the Senior Center.
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

* indicates a required field