Mobility Services Registration Form
Registration requirements
Applicants must be Chesterfield County residents and provide proof that they are aged 60 or older, or have a
disability, or meet federal income guidelines to participate in the Chesterfield County’s Mobility Services.
Acceptable documentation is listed below. Information provided is for documenting and confirming eligibility in
order to provide services.
To apply, complete this form and attach proof of residency and qualifications. Print all information clearly.
Last Name: First Name: MI:
Street:
City: ZIP: Date of Birth: Gender:
Telephone Number: _
Signature Required: Date:
E-mail:
Race or Ethnic background (Federal requirement):
Proof of Qualifications
Please check the appropriate box and attach the documents required in Section A and from Section B.
(Seniors aged 60 or older with a valid Virginia driver’s license or Virginia issued ID card will meet the
requirements of both sections.)
Section A – Proof of Chesterfield County Address listed above. Check one of the following and include a copy
of it with this form.
□ Copy of a utility bill
□ Copy of your valid Virginia driver’s license or Virginia issued photo ID
□ Copy of your Voter Card
□ Copy of lease or other official document with your name and address
Section B — Proof of Qualification - Check one qualification and include a copy of the required documentation
with this form.
□ Aged 60 or older:
• Copy of your valid Virginia driver’s license or Virginia issued photo ID
• Photocopy of your birth certificate
• Medicaid or Medicare Card
□ Disabled:
• Copy of a doctor’s letter
• Social Security statement
• Medicaid or Medicare card
• IEP or MHMRSA Pro-Filer number:
□ Income:
• Copy of a tax return
• Social Security statement
• Medicaid Card
• Pay stub or SNAP paperwork
Mobility Aides - Do you use any of the following when traveling in a vehicle:
□ Wheelchair
□ Scooter or Hoveround
□ Walker
□ Other:
Type of Service Preferred:
□ Access Chesterfield – Shared ride – next day curb-to-curb service - purchase vouchers to pay for services
□ Access On Demand – Same day – point-to-point/door-to-door service – use credit card to pay for services
Fax completed form and documentation to 804-748-1099 or email to Access@chesterfield.gov or mail to:
Citizen Information & Resources, Mobility Services, PO Box 40, 9800 Government Center Parkway,
Chesterfield, VA 23832.
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