ADA Paratransit Certification Application
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The information obtained in this certification process will only be used by the Fort Wayne Transportation Corporation for the provision of transportation services. Information will only be shared with other transit providers to facilitate travel in those areas. The information will not be provided to any other person or agency.

1. Name:______________________________________________________

2. Address, State, Zip Code:______________________________________

______________________________________________________________

3. Telephone # (Home):__________________________________________

4. Telephone # (Work):___________________________________________

5. Date of birth:_________________________________________________

6. What is the disability that prevents you from using the fixed route service?
_____________________________________________________________
_____________________________________________________________

Is this condition temporary?______        If Yes, expected duration:______ 

7. How does this disability prevent you from using fixed route services?
Please explain in detail. Use an additional sheet if necessary.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

8. Are there any other effects of your disability of which we need to be aware?  _____________________________________________________________
_____________________________________________________________
_____________________________________________________________

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