Row edge-slant Shape Decorative svg added to bottom Transportation Proxy Form Fill out this form to get started HomeServicesTransportationTransportation Proxy Form Way2Go Transportation Proxy Form Consumer InformationName First Middle Last Birth Date MM slash DD slash YYYY Proxy #1 Contact InformationProxy Name First Last RelationshipPOA Yes No Home PhoneCell PhoneEmail Proxy #2 Contact InformationProxy Name First Last RelationshipPOA Yes No Home PhoneCell PhoneEmail SignatureConsent I am a consumer of CICOA’s Way2Go Transportation services. I authorize the person(s) listed above to act as my proxy to scheduling transportation on my behalf when I am not able to conduct this transaction personally.Person completing form for Applicant (if applicable): First Last Relationship If you have questions regarding this form, please contact our Department via email at transportation@cicoa.org. You can also reach us by phone at 317-803-6153 CAPTCHA Contact CICOA Way2Go Transportation Service Call: (317) 803-6153 Monday – Friday, 8:00 a.m. – 5:00 p.m. Email: transportation@cicoa.org
