You’re cruising right along! How about telling us a little bit about those vehicles.

{{ service.label }} Please select times for at least one day
No rates selected
{{ totalDailyHours }}
Total Weekly hours = {{ totalWeeklyHours }}

Wow! We’re halfway finished. Can you tell us where you can receive ride requests?

Select all states in which you operate

Please select at least one state

Select all counties in which you wish to pick up riders

{{ state.name }} - Please select at least one county
{{ state.selectedCounties.length }} of {{ state.counties.length }} counties selected

Select all zip codes in which you wish to pick up riders

{{ county.state }} - {{ county.name }} County - Please select at least one zip code
{{ county.selectedZipCodes.length }} of {{ county.zipCodes.length }} zip codes selected
The following rates you have provided are higher than the average in the areas you serve, which may impact the numbers of rides you are assigned.
Would you like to reduce your rates?
Continue

Almost done! Just a few more things we’d like to know before we finish.

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Do you have any certificates you would like us to know about?

If you have copies of your documents, please upload them here or e-mail them to transportation@roundtriphealth.com after you have submitted your form.

Drop file here or click to upload
Image or pdf files with a size less than 20MB

Thanks so much for filling that out! You can review your information below, edit any sections if needed, and then submit your information to us for review.

Company Info
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First Name:
{{ rawModel.first_name }}
{{ isVolunteerForm ? "Last Initial" : "Last Name" }}:
{{ rawModel.last_name }}
Phone Number:
{{ rawModel.phone }}
Email:
{{ rawModel.email }}
{{ isVolunteerForm ? "Volunteer Driver" : "Company Name" }}:
{{ rawModel.company_name }}
Fleet Info
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Service Areas
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Click the edit button to view/Change city, county, and zip code information
Thank you for submitting. We will follow up with you shortly for next steps in the onboarding process.