The University of Toledo

Paratransit Request Form

Please fill out the form completely in order to assure that we receive all of the information. If you have any questions when filling this form out, please give us a call at 419-530-1026.

* these fields must be completed

Name and Contact Information

*Full Name:

*Rocket Number:

*Phone Number:

*Rocket Email:

Preferred Email(if different than above):

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Pickup Request 1

*Beginning Date/Date of Pickup:

*Day/Days of the Week:

Choose Monday(M) Tuesday(T) Wednesday(W) Thursday(R) Friday(F) Saturday(Sat) Sunday(Sun) MWF MW TR MTWR TWRF MTRF MTWRF Sat/Sun

*Time of Pickup:

*Pick Up Location:

*Drop Off Location:

*Do you need a return trip, if so what time:

*Is this pickup repeating or one time?:

Choose Repeating OneTime

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Click Here if you have a Second Pickup

Pickup Request 2

*Beginning Date/Date of Pickup:

*Day/Days of the Week:

Choose Monday(M) Tuesday(T) Wednesday(W) Thursday(R) Friday(F) Saturday(Sat) Sunday (Sun) MWF MW TR MTWR TWRF MTRF MTWRF Sat/Sun

*Time of Pickup:

*Pick Up Location:

*Drop Off Location:

*Do you need a return trip, if so what time:

*Is this pickup repeating or one time?:

Choose Repeating One Time

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Click Here if you have a Third Pickup

Pickup Request 3

*Beginning Date/Date of Pickup:

*Day/Days of the Week:

Choose Monday(M) Tuesday(T) Wednesday(W) Thursday(R) Friday(F) Saturday (Sat) Sunday(Sun) MWF MW TR MTWR TWRF MTRF MTWRF Sat/Sun

*Time of Pickup:

*Pick Up Location:

*Drop Off Location:

*Do you need a return trip, if so what time:

*Is this pickup repeating or one time?:

Choose Repeating OneTime

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Click Here if you have a Forth Pickup

Pickup Request 4

*Beginning Date/Date of Pickup:

*Day/Days of the Week:

Choose Monday(M) Tuesday(T) Wednesday(W) Thursday(R) Friday(F) Saturday (Sat) Sunday(Sun) MWF MW TR MTWR TWRF MTRF MTWRF Sat/Sun

*Time of Pickup:

*Pick Up Location:

*Drop Off Location:

*Do you need a return trip, if so what time:

*Is this pickup repeating or one time?:

Choose Repeating OneTime

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If you have more than four requests to make. You will need to submit the first four and then fill out another form to requests four more. You may submit as many as you need to but only 4 a form.

Submitting a Pickup Request form doesn't guarantee a pickup. If your rides are accepted we will send you a follow up email confirming them or rejecting them.