City of Big Rapids

info@cityofbr.org

226 North Michigan Avenue, Big Rapids, MI, 49307, US

231-592-4040

Section 1 of 1 in this document

City of Big Rapids Dial-A-Ride Public Transit System Standing Call Service Request - Adult

Passenger Name

Home Telephone Number:

Email Address:

Pickup Days of the Week (Please select all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Service Begin Date and Time

Service End Date:

Pickup Location

Destination Location

Daycare Provider Name

Daycare Provider Phone Number

Employer Name

Employer Phone Number

You Must Sign the

Bus Safety Agreement

Passenger Name

I, acknowledge that I have received, read and understand the Passenger Rules and Regulations issued by the City of Big Rapids Dial-A-Ride and agree to abide by the same. I understand that riding the Dial-A-Ride bus is a privilege which can be denied. I agree and understand that our safety on the bus is extremely important to Dial-A-Ride and to me. I will cooperate with Big Rapids Dial-A-Ride transit system to see that the highest degree of safety is maintained at all times.

Required Parent or Guardian Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Office use only: Transportation To/From Dial-A-Ride office (___)

Date: ________________

Books of Tickets Sold at Sale Price:_____________