Veteran Demand Response Service

1. Last Name *
2. First Name *
3. Middle Initial
4.  
5. Male/Female * Male Female Prefer Not to Answer
6. Date of Birth *
7. Street Address *
8.  
9. Apartment Name
10. Building No./Apt. No.
11. City/Town *
12. State *
13. Zip *
14. Home Phone *
15. Work Phone
16. Cell Phone
17. Emergency Contact Name *
18. Emergency Phone *
19. Email
20.  
21. Please attach a copy of your DD Form 214 or Veteran ID Card

I understand the purpose of this evaluation form is to determine my eligibility for Veterans Demand Response Service.  I understand that information provided in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility.  

I understand that providing false or misleading information can result in my eligibility status being revoked.  

1. Click below to approve the application release.  *

   1. Approved
   2. Not Approved

(If no DD Form 214 or Veteran ID Card is available)

1. I certify that the above applicant is a Veteran of the US Armed Services.

   1. Yes
   2. No
2. Agency Representative Name, Title and Organization
3. Agency Representative Signature

Please read the following statement and check those that best describe what you believe to be your ability to use SARTA's Fixed Route bus service and your current transportation needs.  You may select more than one. 

1. I use SARTA's Fixed Route Service frequently.

   1. Yes
   2. No
2. I believe I can learn to ride SARTA's Fixed Route Service, If I were taught.

   1. Yes
   2. No
3. I would utilize fixed route services; however, there are no services available close to where I live.

   1. Yes
   2. No
4. My current employment is not on/near a fixed route.

   1. Yes
   2. No
5. Current Employer Name and Address
6. I have a child(ren) I need to get to daycare as well as my job.

   1. Yes
   2. No
7. Daycare center name and address
8. Number of children that need to get to daycare. 1 2 3 4+
9. I have a disability that prevents me from using fixed route service (Please fill-out Proline ADA application)

   1. Yes
   2. No
10. I am not able to utilized the fixed route service for other reasons (please explain in detail).

If you have any questions or need assistance completing this form, please call: 330.455.2292.

SARTA will provide a determination of eligibility within 21 days of receiveing the Veteran Demand Response Applicaiton and copies of DD Form 14/Veterans Card or verification from an approved Veterans agency.