Application for ADA Paratransit Eligibility

1. Name *

First

Last

2. Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

3. 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? *

If 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) *

9. Do you require a Personal Care Attendant when you travel using transit? *

10. 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).
No

11. 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 *