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
