ADA Paratransit Certification Application
This is page 6. Print this page and fill out pages 1 through 6.

If the person has a cognitive disability, is the person able to:

Give addresses and telephone numbers upon request:
Yes______  No______ 

Recognize a destination or landmark?
Yes______  No______ 

Deal with unexpected situations or unexpected change in routine?
Yes______  No______ 

Inquire, understand and follow directions?
Yes______  No______ 

Safely and effectively travel through crowded and/or complex facilities?
Yes______  No______ 

Describe any other effect of the disability of which Citilink should be aware:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

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

Your Name:__________________________________________________
Business Address:____________________________________________
Business Phone Number:_______________________________________
Signature:____________________________________________________

Mail completed forms to:
Paratransit Services
Citilink
801 Leesburg Rd
Fort Wayne, IN 46808