Transportation Program Submission Form

 

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Would you like to list your transportation program on the COST Website?   To list your transportation system's information, complete and submit the form to the New Jersey Council on Special Transportation.

 

All information listed will be reviewed by COST prior to posting.  COST reserves the rights to determine what is or is not posted.  The New Jersey Council on Special Transportation will make every effort to post within one week after receipt.

 

 

(1) Name of Transportation Program:

 

(2) Agency/Organization Name:

 

(3) Address 1:  

 

(4) Address 2:

 

(5) City:              (6) State:        (7) Zip Code:

 

(8) Tel:                  (9) Fax:

 

(10) Contact Name:

 

(11) Title:

 

 

(12) Type of Agency/Organization:   Municipal   

                                                            Not-for-Profit   

                                                            Volunteer   

                                                            Private-For Profit   

                                                            Other:

 

(13) Phone Number to Schedule an Appointment:

 

(14) Days of Operation:    Monday    Tuesday    Wednesday   

                                        Thursday   Friday    Saturday    Sunday

 

(15) Hours of Operation:

 

(16) Are Advanced Reservations Required?   YES    NO            (17) If Yes How Many Days:

 

(18) What is your Services Area:     e.g. Citywide, City X,Y and Z, etc.

 

(19) Do you travel outside your service area borders?    YES        NO

 

(20) Is your service wheelchair accessible?:        YES        NO

 

(21) Age Eligibility (check all that apply):      Senior Citizens    Disabled    Low-Income   

                                                                         Other

 

(22) If you transport Disabled passengers, from what age?:

 

(23) Do you accept donations?:          YES    NO

 

(24) Explain any donation policy you may have:

 

 

(25) Do you charge a fare?:            YES        NO            (26) If Yes, how much?;

 

(27) Services Type        Door to Door    Curb to Curb    Fixed Route

 

(28) Please check all services which you provide transportation for:

 

non-emergency medical appointments                dialysis                         evening dialysis  

Saturday dialysis                                                  physical therapy           mental therapies

non-competitive (workshops) employment        food shopping               nutrition sites 

competitive employment                                    welfare to work             post-secondary education     

evening mall shopping                                          Veteran Services            Medicaid Services                                     social and recreational activities

Other (please list)

 

(29) Additional Comments: