ADA Paratransit Certification Application Form 1

The information obtained in this certification process will only be used by Citilink. 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.

Name:

 

Address:

 

First:

 

Street:

 

Last:

 

City:

 

Telephone #:

 

State:

 

Home:

 

Zip:

 

Work:

 

Date of Birth:

 

What is the disability which prevents you from using our fixed route service?

Is this condition temporary?  No  Yes

If Yes, expected duration:    

How does this disability prevent you from using fixed route services?
Please explain completely.

Are there any other effects of your disability of which we need to be aware?
If Yes, please explain.