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PARATRANSIT SERVICES EXPRESS BOOKING REGISTRATION FORM

If you have any problems submitting this form, please email this information to XPressBk@DART.org

OR

print out this form after filling it in and mail to:
DART Paratransit
P.O. Box 660163
Dallas, Texas 75266-0163

First Name   

Last Name   

Paratransit I.D. No.   

Address   

Apt/Bldg #   

City/ZIP   

Telephone Number   

Email Address   

If the address listed above is not your current mailing address, please provide your correct mailing address below.

Mailing Address   

Apt/Bldg #   

City/Zip   


Trip Category Listings

To create your own personal trip location list, up to ten choices, use the following categories. The trip categories are provided in a drop-down menu on the form below. Please provide a complete address for trip locations to ensure accuracy.

 >  Alternate  >  Emergency
 >  Bank/Financial Institution  >  Entertainment/Sports
 >  Beauty Shop/Barber Shop  >  Government
 >  Church  >  Grocery
 >  Client Specified 1  >  Home
(Automatic, please confirm above)
 >  Client Specified 2  
 >  Client Specified 3  >  Pharmacy/Prescription
 >  Client Specified 4  >  Physical Therapy/Rehabilitation
 >  Day Care  >  Restaurant
 >  Dialysis  >  Shopping 1
 >  Doctor 1  >  Shopping 2
 >  Doctor 2  >  Visiting
 >  Doctor 3  >  Work
 >  Education    

Personal Trip Registration Form
Example
Trip Category Doctor 1
Location Name Dr. William Smith
Address 4067 Walnut Hill, Professional Building #2
Apt/Bldg #/Suite # Suite #824
City/ZIP Dallas, TX 75402
Telephone Number (214) 826-6667
Comment Field Turn south on Greenville from Walnut Hill
Trip Number One
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Two
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Three
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Four
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Five
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Six
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Seven
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Eight
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Nine
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field
Trip Number Ten
Trip Category
Location Name
Address
Apt/Bldg #/Suite #
City/ZIP
Telephone Number
Comment Field

Please add any additional comments here.

 

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