2. If you qualify and would like to apply for the Emergency Ride Home service, complete and submit the following application form online. You may also print out and complete the application and fax it to (901) 222-9561 or mail it to the AQIB office.To find out if you qualify, please refer to the Policies & Procedures.
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip*
13. Email Address*
15. Nearest major cross street
17. Home Phone*
18. Work Phone
20. Resident County*
21. Round trip miles to work*
23. Please check if you work*

    1. Flexible hours

    1. Saturdays

    1. Sundays
25. What is your normal work schedule?*
27. Is your rideshare a: *

    1. Carpool

    1. Bus Route

    1. Vanpool

    1. Bike
29. Name(s) of people with whom you regularly rideshare
31. Employer Name*
33. Employee Address*
34. County
36. Supervisor's Name*
38. Supervisor's Phone Number
40. Work Phone Number
42. Additional comments/questions:
44. I hearby attest that I share a ride to my worksite at least three (3) days a week or fifteen (15) days each month with the person or persons named above. I further attest that I have read the policies and procedures of the Emergency Ride Home service and agree to comply with those policies and procedures. I hearby release the Regional Transportation Authority, its officers, board of directors, agents and employees from all liability, claims, suits, demands or damages for personal injury, loss, theft or damage to my personal property; loss of income; or consequential damages resulting from delays or absence of cab or rental car; or termination of the program.

    1. By checking this box, you confirm the above statement.
46. Shelby County Health Department, Air Quality Improvement Branch, 814 Jefferson, 4th Floor, Memphis, TN 38105(901)222-9594 Fax (901)222-9561johnathan.dugger@shelbycountytn.gov
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

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