Please enable JavaScript in your browser to complete this form.1. Name *FirstLast2. Street Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address (if different)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code3. Phone (Home) *Phone (Work)4. Date of Birth *5. What is the disability which prevents you from using our fixed route service? *Is this condition temporary? *YesNoIf yes, please indicate the expected recovery date:6. Please briefly describe how your disability prevents you from using the fixed route system. *7. Are there any other effects of your disability of which we need to be aware? *8. Do you use any of the following aids to mobility? (Check all that apply) *Manual wheelchairElectric wheelchairPowered scooterCaneCrutchesGuide DogOther9. Do you require a Personal Care Attendant when you travel using transit? *YesNo10. Are you able to complete any of your travel needs on the fixed route system? *Yes (If yes, please explain; if your answer is yes, this will not effect your chances of becoming eligible for ADA paratransit service). No11. For planning purposes only, please answer the following. Approximately how many days per month do you expect to use paratransit services? * Where will most of your trips be to and from? *Acknowledgement *I hereby certify that the information given above is correct. Submit