Laserfiche WebLink
2. TYPE OF APPLICANT Public County Government <br />3. TYPE OF TRANSIT SYSTEM Single -County <br />4. TYPE OF SERVICE — (check all that apply) <br />El Demand Response <br />7 Fixed Route <br />121 Subscription <br />❑ Other: (specify below) <br />Q Deviated Fixed Route <br />5. SERVICE OPTIONS — (check all that apply) <br />General Public <br />❑ Brokerage (Contractual service not a referral) <br />Human Service <br />❑ Other: (describe below) <br />6. PURCHASE SERVICE - List agencies that purchase service from the transit system. Note: List agency ONCE <br />Agency 1 <br />Agency 2 <br />Name: Lee County Department of Social Services <br />Name: Lee County Industries <br />El Check if agency purchased service last year <br />0 Check if agency purchased service last year <br />List Programs Served: <br />List Programs Served: <br />1) Medicaid <br />1) Vocational Rehabilitation <br />2) Work First <br />2) <br />3) Division of the Blind <br />3) <br />4) Child Services <br />4) <br />5) Youth Services <br />5) <br />Agency 3 <br />Agency 4 <br />Name: Lee County Senior Services <br />Name: Central Carolina Community College <br />FZI Check if agency purchased service last year <br />Q Check if agency purchased service last year <br />List Programs Served: <br />List Programs Served: <br />1) General Transportation <br />1) Adult Education <br />2) Medical <br />2) High School Equilivancy <br />3) <br />3) <br />4) <br />4) <br />5) <br />5) <br />Agency 5 <br />Agency 6 <br />Name: Sanford Health and Rehabilitation <br />Name: Lee County Health and Rehabilitation <br />PI Check if agency purchased service last year <br />Q Check if agency purchased service last year <br />List Programs Served: <br />List Programs Served: <br />1) Medical <br />1) Medical <br />2) <br />2) <br />3) <br />3) <br />4) <br />4) <br />5) <br />5) <br />Agency 7 <br />Agency 8 <br />Name: Piedmont Consortium <br />Name: Sandhills Mental Health <br />El Check if agency purchased service last year <br />Check if agency purchased service last year <br />List Programs Served: <br />List Programs Served: <br />1) Medical <br />1) Day Treatment- Medical <br />2) <br />2) <br />3) <br />3) <br />4) <br />4) <br />5) <br />5) <br />Agency 9 <br />Agency <br />Name: Commons Nursing and Rehabilitation <br />10 Name: Stevens Center <br />_Liberty <br />0 Check if agency purchased service last year <br />Check if agency purchased service last year <br />List Programs Served: <br />List Programs Served: <br />1) Medical <br />1) Rehabilitation <br />2) <br />2) <br />3) <br />3) <br />4) <br />4) <br />5) <br />5) <br />❑ Check box at left if you serve more than 10 agencies and complete Continuation worksheet. <br />Page 2 <br />