MobilityShare Intake Form
Thank you for your interest in CarShare Vermont's MobilityShare Program!  As funding allows, we're able to offer free memberships to income-qualifying individuals and families to lower the cost of joining CarShare Vermont. Please fill out the form below to tell us a little bit more about yourself so we can see if the program is a good fit. If you have any questions call (802) 861-2340 or email info@carsharevt.org.
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Have you been a member of CarShare Vermont in the past? *
Your full name *
Address *
Please include your full address including your city or town of residence.
Phone number *
Email *
If you do not have an email please put "no email".
Do you receive or qualify for any of the following benefits? Please check all that apply.
Have you had a valid driver's license for at least 2 consecutive years? *
Have you had 4 or more moving violations in the last 3 years? *
Have you had any major moving violations in the last 7 years? *
e.g. driving with a suspended license, reckless driving, excessive speeding, etc.
Have you had 3 or more at-fault accidents in the last 3 years? *
Have you had any alcohol-related violations in the last 7 years? *
What is your household's annual income before taxes? *
Why are you interested in joining CarShare Vermont's MobilityShare program, and  how do you think it  will help you meet your transportation needs? *
How did you hear about the MobilityShare program? *
If you we're referred by a current member or one of our partner organizations (i.e. CVOEO, CHT, BHA, etc.) please explain.
Do you own a vehicle? *
If yes, please include the age, make, and model of the vehicle(s) you own.
How do you currently meet your transportation needs? *
Please check all that apply.
Required
What kind of trips do you expect to use CarShare Vermont for? *
Please check all that apply.
Required
How much do you expect to drive each month? *
How many people live in your household? *
Please only include people that share your finances in this number count.
How much do you currently spend on transportation each month? *
Please include money spent on gas, bus passes, taxis, Uber/Lyft, etc.
How much do you expect to spend on CarShare Vermont each month? *
Please note that driving rates are $6.50/hour + .38cents/mile or $65/day (first 100 miles included, then .38 cents/mile after).
Do you have a credit or debit card for payment? *
What kind of technology do you have at home? *
Please check all that apply.
Required
What is your race/ethnicity? *
Please check all that apply
Required
Please indicate your age range below. *
What is your highest level of education? *
Who lives with you? *
Please check all that apply.
Required
What is your employment status? *
Is there anything else you'd like to share about yourself?
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