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Intake
This form is used for eligibility and referral  purposes
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1. Name *
2. Address
3. What best describes your circumstances? *
4. Do receive SSI benefits, Food stamps, or Low-income Housing Assistance? ( Items are needed for verification purposes)
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5. If you answered yes to Number 4. Which one?
6. What essential service do you need transportation for? Please specify
7. How would Diligent Transportation providing you transportation service improve your quality of life? *
8. What other transportation options do have currently have ? *
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