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Port Authority Bus Terminal Advisory
Council (PABTAC) Membership Application
Name:
Address:
City:
State:
Zip:
Daytime Phone: ( )
Evening Phone: ( )
Email Address:
☐Male ☐ Female ☐ Prefer to not to self-identify
How frequently do you use or visit the Port Authority Bus Terminal, on average, per week? (Make only one selection.)
☐ Fewer than 3 times a week ☐ 3-5 times a week ☐ 6-13 times a week ☐ More than 13 times a week
If you are a commuter, where is your primary destination? (Make only one selection.)
☐Manhattan – North of 59
th
St (Uptown) ☐Manhattan – Between 14
th
and 59
th
streets (Midtown) ☐ Connecticut or Pennsylvania
☐ Manhattan – South of 14
th
St (Downtown) ☐Brooklyn, Queens, or the Bronx ☐New Jersey ☐Other _____________
If you are a commuter, where is your origin when traveling to the Bus Terminal (or from, if you “reverse commute” into NJ)?
Town, County, Neighborhood, etc.: ____________________________________________________________________________
Which gate/levels do you typically use?
☐1-85 (Lower Level) ☐200 gates (Level 2) ☐300 gates (Level 3) ☐400 gates (Level 4)
What carrier do you typically use?
☐ NJ Transit ☐Academy ☐Adirondack Trailways ☐Peter Pan ☐CoachUSA, Shortline, Suburban, Rockland, or Community
☐ DeCamp ☐Greyhound ☐Lakeland ☐ Martz Trailways ☐Other ____________________
If you commute through the Bus Terminal, when do you do so? (Select up to 3 choices.)
☐ Weekday Commute (work/school) ☐ Weekday (Personal matters/social) ☐Overnight (Weekday)
☐ Weekend Commute (work/school) ☐ Weekend (Personal matters/social) ☐Overnight (Weekend)
If you commute through the Bus Terminal, at what time do you typically arrive and leave?
Arrival Time: ______________________________ Departure Time: _______________________
If you commute through the Bus Terminal, how to you typically reach your final destination?
☐ Walk ☐Subway ☐ NYCT Bus ☐ Bike or Scooter ☐ Taxi or Ride-share (Uber, Lyft, Via, etc.) ☐ Other: __________
If you do not typically travel through the Bus Terminal, what is your primary relationship with the building?
☐Neighborhood Resident (Hell’s Kitchen, Chelsea, Times Sq.) ☐Local Business Owner ☐NYC Resident ☐Other: ____________
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If you do not travel, when are you typically interacting with the Bus Terminal?
☐ Weekday ☐Overnight Please describe in what capacity: _____________________________________________
☐ Weekend ________________________________________________________________________
☐ Yes ☐ No
☐ Yes ☐ No
Do you have any financial ties to the Port Authority of New York and New Jersey? ☐ Yes ☐No
If so, please explain:
☐ Yes ☐ No
In the space below, please outline why you wish to serve on the PABTAC. Include your community involvement/volunteer activities.
In the space below, please share your knowledge or interest in regional transit issues:
Describe how you, as a member of the PABTAC, would solicit feedback from, or disseminate information to, fellow PABT users:
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The Port Authority of New York & New Jersey/Port Authority Trans Hudson Corporation (PATH) may use or disclose the individual information collected on this form
to fill positions on the Port Authority Bus Terminal Advisory Committee (PABTAC) and comply with Title VI of the Civil Rights Act of 1964. Providing this information
is voluntary, but an individual who does not submit a complete application, with the exception of the self-identification of your race, ethnicity, and income, may not be
considered as a candidate for membership on the PABTAC. Except for the information regarding your race, ethnicity, and income, information from this form may be
disclosed, as follows: for law enforcement purposes; to congressional offices or offices of elected officials inside or adjacent to the Port District of the Port Authority of
New York and New Jersey; to contractors, grantees, and others; in connection with administrative claims, complaints and appeals; and in connection with litigation.
Selected information about PABTAC members, excluding the personal information and the information on race, ethnicity and income, may be subject to disclosure to
the public under the Port Authority's Freedom of Information Code.
In order to comply with certain governmental record keeping and reporting requirements for administration of civil rights laws and regulations to which the Port
Authority/PATH is subject, we invite you to voluntarily self-identify your race, ethnicity, and income. Submission of this information is voluntary, and refusal to provide
it will have no bearing of your application. All such information will be kept strictly confidential and will only be used in accordance with provisions of applicable laws,
orders and regulations.
Signature:
Date:
Which best describes your race and/or ethnic background?
☐ African American/Black ☐ American Indian or Alaska Native ☐ Asian or Pacific Islander ☐ Caucasian/White
☐ Latino/Hispanic ☐ Multi-racial ☐ Other: ______________________
What best describes your age range?
☐ Under 18 ☐18 - 24 years ☐ 25 – 34 years ☐ 35 – 44 years ☐ 45 – 54 years ☐ 55 – 64 years ☐65 years +
What language(s) do you speak regularly in addition to English (if any)?
_________________________________________________________________________________________________
Which best describes your level of English proficiency? ☐ Fluent ☐ Conversational ☐ Minimal
What is your household's annual income range before taxes?
☐ Under $15,000 ☐ $15,000-$24,999 ☐ $25,000-$34,999 ☐ $35,000-$49,999
☐ $50,000-$74,999 ☐ $75,000-$99,999 ☐ $100,000-$149,999 ☐ $150,000 and Over
How many people live in your household (including you)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 or More
Indicate the population(s) of which you belong or advocate for, if any? (optional question)
☐ Low-income ☐ Disabled ☐ Ethnic, Racial or Sexual Minority ☐ Limited English Proficiency ☐ Elderly
☐ Other: _______________________________________________
What level of education have you completed?
☐High School/GED ☐ Some College or Vocational ☐ Two-Year Degree
☐Four-Year Degree ☐ Graduate ☐ Post-Graduate
Email your Application to: PABT[email protected]