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Shared Ride Program Participation Form
`The COUnty of Han waN Mass Tirains�t Agency offers a flE%ib�e shared dde prograiai operated by
taxis. I-rav(-,rp is unkryflted and the ('"Ounty wHI siubsp6ze up to $15.80 per tdp, Passengers aire
responsVe to pay the baWice of the rate. 'Taxes accept cash onpy.
Pie,ase c�or,rippete the to to pairtidpate in the prograrn an(J SUbrrft t-0 the COLlinty of FiawaN
Mass -rranspt Agency apong wfth a COPY Of YOUr photo identffication card.
Choose orie of the du Howirig to seii-nd the cornppeted forni:
* Fax� (808) 961-8745
* ErnaH: heigonbu, gyyakCOLS QQY
* US Mail: 25 AupL,6 Street, Hio, F11 96720
* Drop off pocabow Mo'oheat.j Bus TerrTlk'op, 329 Kanr'iehaffieha Ave., HHo 96720
West Hak `Jvpc Center, 74-.50,14 Ane IKeohokaVe Hwy., Mudd D
Kakiija- Kona, F11 96740
Participants Name:
(PlInt) ast
Mailing Addressm
Physical Address -
Phore No,:
city
(In(lude Area Code)
Identificadon: Drpver's Ucense
Sgnaturew
Rrst RL
P.O,, Box oi'. St�reet
State Zip Code
Stato,'., Zip Code
Aiteniate Phone Nurnt)er
State L [), Other
Date:
Pleaise Spe&y
Effectwe 613012023