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.

9. 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______ 

10. Do you require a Personal Care Attendant when you travel using public transit. Yes______  No______ 

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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