ADA Paratransit Certification Application
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Authorization for Release of Information

In order to allow Citilink to evaluate your request, it may be necessary to contact a physician or other professional to confirm the information you have provided. Please complete the following information and authorization form.

Please check one of the following:

____Physician
____Health Care Professional       
____Rehabilitation Professional

* * * * * * * * * * * * * * * *

The above is familiar with my disability and is authorized to provide the necessary information to Citilink for completion of certification.

Name:_______________________________________________________

Address:_____________________________________________________

City:_________________________________________________________

State:_______________________________________________________

Zip Code:____________________________________________________

Daytime Phone:_______________________________________________

* * * * * * * * * * * * * * * *

Please Print Name of Applicant:__________________________________

Applicant’s Date of Birth:________________________________________

Applicant’s Signature:__________________________________________

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