ADA Paratransit Certification Application
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The following information will be used to ensure that an appropriate vehicle is utilized to provide your transportation and that an accurate analysis of your trip request can be made by Fort Wayne Citilink.

8. Do you use any of the following aids for mobility? (Check all that apply)

 Manual wheelchair______ Electric wheelchair _________

Powered scooter_______Cane ______ Crutches _________

Personal care attendant _______________Guide dog _____________

9. Do you require a Personal Care Attendant when you travel using public transit. _________

Can you travel 200 feet without the assistance of another person? Yes _____No ______ Sometimes _____

Can you travel 1/4 mile without the assistance of another person? Yes ________ No _____ Sometimes _____

Can you travel 3/4 mile without the assistance of another person? Yes________No _____Sometimes______

Can you climb three 12-inch steps without assistance? Yes______ No_______ Sometimes ___________

Can you wait outside without support for ten minutes? Yes _______No _______ Sometimes __________

I hereby certify that the above information is correct.

Signed: ________________________________________________________________

Date: __________________________________________________________________

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