Transit Program Pre-qualification Survey

Name *

First Name

Last Name

Phone Number *

(###)

###

####

Preferred Language *

English

Spanish

Portuguese

Haitian Creole

Other…

Preferred Method of Communication *

Phone

Text Message

Email

No Preference

What is your household source of income?

Employment

SSI/SSDI

Cash Assistance (TAFDC)

Unemployment

None

Other...

Are you a recipient of any of the following public benefits?

SNAP (food stamps)

WIC

MassHealth

Section 8 Voucher holder

LIPHEAP

Child enrolled in Head Start

None or I don't know

Do you currently have a free or discounted MBTA pass?

Yes

No