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Rider's First and Last Name *
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Do you require wheelchair accessible transportation? *
Year of Birth *
For statistical purposes, and to determine eligibility for certain automatically applied fare subsidies
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Street Address *
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Mailing Address *
If different than your street address, please list under "other" - We use this information to mail out important policies and changes to our service!
Town *
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Postal Code *
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Email Address
If you check regularly and would prefer us to contact you this way!
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Phone Number(s) *
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Emergency Contact Name *
Someone we can contact in case of an emergency during a trip
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Emergency Contact Phone Number *
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Relationship *
Your emergency contact's relationship to you
Mobility Issues
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OPTIONAL: Why are you interested in using this service?
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Other Information:
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Consent for Collections, Use and Discloser of Information
In order to accomplish our service, we collect personal information from our riders. This information is not shared by Queens County Transit, except for statistical purposes (where personally identifiable information is not included), and is used by our organization to tailor our services to your needs.
Do you consent to the collection, use and discloser of your information? *
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