Delaware City FLEX Request
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FLEX Trip Request Info
ALL REQUESTS MUST BE RECEIVED BY 12:00 PM THE DAY PRIOR TO THE DAY OF THE TRIP. NO REQUEST WILL BE ACCEPTED FOR TRIPS MORE THAN SEVEN DAYS IN ADVANCE. FOR MONDAY, REQUESTS MUST BE RECEIVED PRIOR TO 12:00 PM FRIDAY. ALL TRIPS ARE SUBJECT TO AVAILABILITY. ALL QUESTIONS MARKED WITH A RED ASTERISK (*) MUST BE ANSWERED.
FIRST NAME *
LAST NAME *
PHONE NUMBER *
DATE OF BIRTH *
MM
/
DD
/
YYYY
DATE OF TRIP *
MM
/
DD
/
YYYY
PICKUP ADDRESS (MUST BE WITHIN DELAWARE CITY) *
DESTINATION ADDRESSS (MUST BE WITHIN DELAWARE CITY) *
REQUESTED PICK UP TIME (Provide if no Appointment time, but preferred time of trip--understanding all times based upon availability)
Time
:
APPOINTMENT TIME (IF NEEDED-- pick up times will be based upon arriving by this time )
Time
:
REQUESTED RETURN TIME (if requiring a return trip)
Time
:
ANY SPECIAL MOBILITY REQUIREMENTS (i.e. wheelchair, walker, requires lift) Please review the IMPORTANT INFORMATION at the bottom of page to make sure FLEX is the right service for you
REASON FOR TRIP *
EMAIL ADDRESS (FOR EMAIL REPLY *necessary for confirmation of receipt of request)
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