Orange County NC Website
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2. TYPE OF APPLICANT Public County Government <br />3. TYPE OF TRANSIT SYSTEM Single-County <br />4. TYPE OF SERVICE - (check all that apply) <br />~ Demand Response ~ Fixed Route <br />~ Subscription ^ Other: (specify below) <br />~ Deviated Fixed Route <br />5. SERVICE OPTIONS - (check all that apply) <br />~ General Public ^ Brokerage (Contractual service not a referral) <br />~ Human Service ^ Other: (describe below) <br />6. PURCHASE SERVICE -List agencies that purchase service from the transit system. Note: List agency ONCE <br />Agency 1 Agency 2 <br />Name: Orange County social Services Name: Orange County Senior Centers <br />~ Check if agency purchased service last year ~ Check if agency purchased service last year <br />List Programs Served: List Programs Served: <br />1) low income 1) 60+ population <br />2) transit dependant 2) nutrition <br />3) Medicaid 3) day trips <br />4) 4) <br />5) 5) <br />Agency 3 Agency 4 <br />Name: Orange Enterprises Name: <br />Q Check if agency purchased service last year ^ Check if agency purchased service last year <br />List Programs Served: List Programs Served: <br />1) disabled to workshops 1) <br />2) 2) <br />3) 3) <br />4) 4) <br />5) 5) <br />Agency 5 Agency 6 <br />Name: Name: <br />^ Check if agency purchased service last year ^ Check if agency purchased service last year <br />List Programs Served: List Programs Served: <br />1) 1) <br />2) 2) <br />3) 3) <br />4) 4) <br />5) 5) <br />Agency 7 Agency 8 <br />Name: Name: <br />^ Check if agency purchased service last year ^ Check if agency purchased service last year <br />List Programs Served: List Programs Served: <br />1) 1) <br />~) 2) <br />3) 3) <br />4) 4) <br />5) 5) <br />Agency 9 Agency <br />Name: 10 Name: <br />^ Check if agency purchased service last year ^ Check if agency purchased service last year <br />List Programs Served: List Programs Served: <br />1) 1) <br />2) 2) <br />3) 3) <br />4) 4) <br />5) 5) <br />^ Check box at left if you serve more than 10 ag encies and complete Continuation worksheet. <br />Page 2 <br />