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2. Douglas County residents may submit this form to be added to the Transportation Voucher Program Waitlist.

   
   

   Make sure to provide accurate contact information so that you may be notified to enroll in the program.

   
   

   Please submit only one form per person!

4. Contact Information
6. First Name*
7. Last Name*
9. Phone Number*
10. Phone Number 2

    Optional

11. Email Address
13. Address*
15. City*
    -- Select One --DouglasvilleWinstonLithia SpringsVilla RicaAustell
16. State
    -- Select One --GA
17. Zip Code*
19. About You
21. Select your eligibility category:*

    To participate in the voucher program, you must fall under one of the categories below.

    1. Senior (age 65 or older)
    2. Person with a Disability
    3. Both
23. Age*
24. Marital Status

    1. Single
    2. Married
25. Household Size

    1. 1
    2. 2
    3. 3
    4. 4+
27. Annual Income
    -- Select One --< $25,000$25,000 to $35, 000> $35,000
28. Source of Income

    Check all that apply.

    1. Social Security Retirement Benefits
    2. Supplemental Security Income (SSI)
    3. Social Security Disability Insurance (SSDI)
    4. Full Time Work
    5. Part-time Work
    6. Family Support
30. Disability and/or Mobility Limitations

    You are not required to share any private health information. Please briefly describe your disability and any mobility limitations you have.

32. Frequent Trips and Destinations

    Indicate the type of trips or destinations for which you require transportation assistance. Please check all that apply.

    1. Dialysis
    2. Medical Appointments
    3. Physical Therapy
    4. Work/Employment

    1. School
    2. Shopping/Personal Care
    3. Visiting Family/Friends
    4. Outside Douglas County
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field