MARTA_Card_Application

MARTA Card Assistance Application

Full Name*

Date of Birth*

Date

Phone Number*

Email Address*

example@example.com

Current Address*

Do you receive other transportation help from another program?*

YesNo

If yes, which program

Are you enrolled in any of our other programs?*

YesNo

If yes, which programs

Why do you need a MARTA card right now?*

Please share your situation so we understand how this program helps. Your answer may also help us show why this program is important for funding.

Have you received a MARTA card from us before?*

YesNo

If Yes, When?

How often do you use public transportation? (Daily, Weekly, Occasionally)*

How did you hear about our program? *

Referred by (211, caseworker, walk-in, web)

Signature*

Date*

Date

By submitting this application, you give Group Home Alliance, inc. permission to use your name, likeness (including photos or video), and story for program awareness, social media, fundraising, and grant reporting. If you do not wish for your name, likeness, or story to be used in this way, please do not apply to the MARTA Card Program.

I have read and agree to the terms above, including allowing Group Home Alliance, inc. to use my name, likeness, and story for program awareness, social media, fundraising, and grant reporting.*

Consent Confirmation