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2. This online application is for Gloucester County residents requesting transportation for the Adult Center for Transition (ACT) programs. Please be aware this transportation, if approved, is provided Monday through Thursday, no Fridays, weekends, or holidays. A Department of Transportation Services (DTS) staff member will reach out by telephone and / or email advising the consumer of the status of the application. Once a time slot, days, and the location is approved, any subsequent changes in the aforementioned criteria of your original application may result in Gloucester County being unable to meet the new requirements due to previous commitments. In this case, you may be placed on a waiting list until such time availability arises on a route. You would also be responsible for your own transportation to and from the program during this period. The completion of this application does not guarantee approval or utilization of our services. When services cannot immediately be rendered, the consumer will be placed on a waiting list. When availability arises for you, we will contact you to verify you still desire transportation. You are invited to contact us at any time to check your status on the waiting list. Note: A new / update application must be filled out for each subsequent semester and summer program. Please check the appropriate box; new or updated. Please call 856-686-8355 with any questions regarding this process.

4. Name of Applicant*
5. Application Type*
   -- Select One --New ApplicationRenewal Application
7. Email Address
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Emergency Phone Number
18. Emergency Contact Person*
19. Date of Birth*
    Date of Birth
20. Last 4 Digits of SS#*
22. Gender*

    1. Female
    2. Male
24. Mobility Aids*
    -- Select One --CraneCrutchesElectric WheelchairManual WheelchairMotorized ScooterWalkerNone
26. Type of Disability*

    1. Cognitive
    2. Hearing
    3. Mental
    4. Mobility
    5. Oxygen Tank
    6. Service Animal
    7. Vision
    8. None
28. Please select where you attend ACT*
    -- Select One --ACT 1 at RCGC Main Campus - Tanyard RoadACT 2 at ACT Center - Salina Road
30. Please select each day that you will need transportation. Please be advised that there is not transportation provided on Saturday, Sunday, or Holidays.*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
32. Please select the time your ACT program starts and ends*
    Please select the time your ACT program starts and ends Start Time

    —

    Please select the time your ACT program starts and ends End Time
34. Referring Agency or Person
36. Do you currently use New Jersey Access Link Services to get to work, school, or training?*

    1. Yes
    2. No
37. If you answered No to previous question, have you ever applied for New Jersey Access Link Services?*

    1. Yes
    2. No
38. Have you ever been denied New Jersey Access Link Services?*

    1. Yes, I have
    2. I have not
40. By submitting you understand that this is only an application and does not guarantee transportation services. A Department of Transportation Services (DTS) representative should contact you in 3 to 5 business days. The completion of this application does not guarantee approval or utilization of the service. Normally, there is a waiting list for ongoing Vocational Transport. Our DTS representative that contacts you will explain in more detail. Thank you for completing the DTS questionnaire.
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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field