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CORPORATE ACCOUNT APPLICATION
Business Information
2026-05-07
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Account Contact
Alternative Contact
Billing contact
Same As Account Contact
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Is this account being set up for one specific passenger
YES
NO
Passenger Information
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Is passenger a minor
YES
NO
Select Age
Under the age of 10
10 and above
Car seat required
Booster seat required
Harness
Supplied by
Dignity Transportation
Customer
Supplied by
Dignity Transportation
Customer
Can the child be dropped at the home alone
YES
NO
Can the child be dropped at the destination alone
YES
NO
Guardian Contact Information
Confirmation/Reminder Information
A confirmation email will be sent when placing your order
YES
NO
An email and / or text reminder will be sent out prior to the scheduled transportation date
YES
NO
TEXT
Email
BOTH
Transportation Information
Type of Transportation
Ambulatory
Wheelchair
Stretcher
Ambulatory
Ambulatory but requires wheelchair accessible vehicle
Requires cam strap for harness
Requires seat belt lock
Requires hand to hand service
YES
NO
Passenger has a cognitive impairment
YES
NO
Passenger has a visual impairment
YES
NO
Passenger has a hearing impairment
YES
NO
Passenger is non communicative
YES
NO
Passenger is accompanied by a service dog
YES
NO
Requesting On Line Booking
YES
NO
Wheelchair Options
Manual
Power
Scooter
Ambulatory but requires wheelchair accessible vehicle
Wheelchair size
Wheelchair less than 30"
Wheelchair less than 32"
Wheelchair less than 33"
Wheelchair less than 34"
Wheelchair less than 35.5"
Wheelchair less than 36.5"
Requires hand to hand service
YES
NO
Passenger has a cognitive impairment
YES
NO
Passenger has a visual impairment
YES
NO
Passenger has a hearing impairment
YES
NO
Passenger is non communicative
YES
NO
Passenger is accompanied by a service dog
YES
NO
Passenger is over 250 Pounds
YES
NO
Passenger uses Oxygen
YES
NO
Passenger uses Oxygen
Over 250 Pounds
Stairs
Customer has regular, on going, scheduled transportation needs (Dialysis / Physio Therapy / School / Daycare etc)
YES
NO
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
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Wednesday
Thursday
Friday
Saturday
Sunday
Monday
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Friday
Saturday
I hereby agree to all the terms and conditions as found at www.dignitytransportation.com
I hereby agrees that these Terms & Conditions may change without notice
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