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Transportation Request
Full Name
Birth Date
Phone
Physical Address
Postal Code
Mailing Address
Postal Code
Use same as physical address
Email
Cell number
Do you own a vehicle?
Yes
No
If so, why do you need CTC transportation service?
Why will you use the service?
Are you a person with reduced mobility?
Yes
No
If yes, what assistance do you use?
Folding walker
Non-folding walker
Cane
Guide dog or service dog
Other
Please identify other assistance you will need in order to use our service.
Please note if the customer requires an attendant or companion, that person must be present at the time of departure and return.
How many reside in your home?
Do you have dependent children (18 and under)?
Yes
No
Person to contact in case of emergency.
Relationship to applicant
Phone or cellphone.
How did you hear of the Restigouche Community Transportation?
Signature of applicant
Date
You agree to our
policy
I certify that the information provided on this form is accurate and complete. I understand that any false statement may lead to refusal or revocation of my registration with the Restigouche Community Transport. I undertake to respect the rules and regulations of the service. I understand that only information necessary for my travel, my safety and my comfort will be transmitted to drivers/RCT organizers/volunteers who will offer me the service.