Client Registration

Clients of this service could be individuals with low income, students, a person losing their mobility, persons who cannot drive a car.

If you would like more info on your registration, please do not hesitate to contact through any of the methods at the bottom of the page.

1. Personal Information

Male   Female
English   French

2. Do you own a car?

Yes   No

3. Why will you use the services?

4. Are you a person with reduced mobility?

Yes   No
Yes   No

Please note: If the customer requires an attendant or companion, that person must be present at the time of departure and return.

5. Do you have any pets that may require transportation? If so, please specify.

6. What is the size of your family? (How many reside in your home?)

7. Do you have dependent children (18 and under)?

Yes   No

8. Person to contact in case of emergency.

9. How did you hear about Chaleur Transportation Cooperative?

10. Application declaration

I certify that the information provided on this form is accurate and complete. I understand that any false statement may lead to refusal or revocation of my registration with the Chaleur Transportaion Cooperative. I undertake to respect the rules and regulations of the service. I understand that only information necessary for my travel, my safety and comfort will be transmitted to drivers/CTC organizers/volunteers who will offer me the service.