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JTA RideShare Program Authorization Form 2024-2025 Program Year

Organization Name:

Mailing Address *

City, State, Zip *

Nonprofit Category *

Do you serve any of the following populations? *

Disabled
Veterans
Children
Seniors
Not Applicable

Do your clients have access to mobile devices? *

Yes
No

If yes, which mobile pass options would your organization benefit from?

1-Day Pass
3-Day Pass
7-Day Pass
31-Day Pass

How many mobile passes will you need per quarter? Please include amount and type. (ex. 20 31 day passes) *

If your clients do not have mobile devices, which Star Pass would your organization need?

1-Day Pass
3-Day Pass
7-Day Pass
31-Day Pass

How many Star passes will you need per quarter? Please include amount and type. (ex. 20 31 day passes) *

Names of Individuals authorized to sign for monthly allocations (2 required)

Name

Email *

Phone *

Name 2 *

Email 2 *

Phone 2 *

Supervisor Name: *

certifies that the recipients of all passes and/or tickets are economically (income at 150 percent or below the Federal poverty guidelines) and transportation disadvantaged and are eligible to receive transportation assistance in accordance with Section 427 FL Statutes. By signing below you verify your organization is adhering to the proper use of these passes. Improper use or egregious requests are grounds for termination from the program.

There is a required program fee of $100. You can pay online or you can mail checks/money orders made out to the Nonprofit Center of Northeast Florida. to: Nonprofit Center attn.: JTA RideShare Program, 40 East Adams Street, Suite 100, Jacksonville, FL 32202. No payments or forms will be accepted in person.

THE VIRTUAL JTA ORIENTATION ON OCTOBER 23rd IS MANDATORY FOR ALL PROGRAM PARTICIPANTS. FEES AND APPLICATIONS ARE DUE NO LATER THAN OCTOBER 31ST PROGRAM FEES ARE NONREFUNDABLE.

Timeout Warning

JTA RideShare Program Authorization Form 2024-2025 Program Year