Citizens Advisory

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Coast Transit Plus
Client Application

Optional: To download the application, fill it out and send it in, please click here to download.

Please fill out this form completely. Uncompleted forms will be discarded.
Fields marked with * are required.

Applicant Information

* Last Name:

* First Name:

* Email Address:

* Social Security Number:

Address:

Apartment / Unit #:

City:

State:

Zip Code:

* Phone Number:

Alternate Phone Number:

Date of Birth:

Sex:

Doctor / Physician Name:

Doctor / Physician Phone Number:

Emergency Contact Person:

Emergency Contact Person's Relationship:

Emergency Contact Person's Phone Number:

Reasons for riding van

Please check all of the reasons that apply:

Medicaid Receiver
Medicare Receiver
Have difficulty standing/waiting for more than 10 minutes
Have difficulty hearing
Have difficulty seeing
Have special medical problem (Heart, diabetes, epilepsy, etc.)
Require special assistance boarding/de-boarding/escort
Use a wheelchair
Use an electric scooter
Use a walker
Use a cane

I understand that any false answer, statements or implications made by me on this application or other required documents shall be considered sufficient grounds for denial.

This certified that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

If you click submit, you are giving Coast RTA your electronic signature, which is binding in a court of law.

* This is a printer friendly version of the original page, made to save you ink and paper.

Ride Coast RTA!

Coast Transit Plus
Client Application

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Citizens Advisory

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