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2. TYPE OF APPLICANT <br />3. TYPE OF TRANSIT SYSTEM <br />4. TYPE OF SERVICE — (check all that apply) <br />❑Demand Response <br />OSubscription <br />❑Deviated Fixed Route <br />5. SERVICE OPTIONS — (check all that apply) <br />[ , ]General Public <br />I , lHuman Service <br />Public County Government <br />Single- County <br />❑ Fixed Route <br />❑ Other: (specify below) <br />❑ Brokerage (Contractual service not a referral) <br />❑ Other: (describe below) <br />6. PURCHASE SERVICE - List agencies that purchase service from the transit system. Note: List agency ONCE <br />Agency <br />1 <br />Name: DSS <br />Check if agency purchased service last year <br />List Programs Served: <br />1) Medicaid <br />2) Doctors Appointments <br />3) Job Search <br />4) Dialysis <br />5) Rehab <br />Agency <br />3 <br />Name: City of Concord <br />Check if agency purchased service last year <br />List Programs Served: <br />1) ADA Paratransit <br />2) <br />3) <br />4) <br />5) <br />Agency <br />5 <br />Name: <br />Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />Agency <br />7 <br />Name: <br />Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />Agency <br />9 <br />❑Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />Agency 2 <br />Name: <br />Aging <br />0 <br />Check if agency purchased service last year <br />List Programs Served: <br />1) Meal Sites <br />2) Doctors Appointments <br />3) Dialysis <br />4) <br />5) <br />Agency 4 <br />Name: <br />❑ <br />Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />Agency 6 <br />Name: <br />❑ <br />Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />Agency 8 <br />Name: <br />❑ <br />Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />Agency <br />10 Name: <br />❑ <br />Check if agency purchased service last year <br />List Programs Served: <br />1) <br />2) <br />3) <br />4) <br />5) <br />❑Check box at left if you serve more than 10 agencies and complete Continuation worksheet. <br />G -1 <br />Attachment number 3 \n <br />Page 2 <br />Page 89 <br />