ADA Paratransit Certification Application Page 1 of 6

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): (Work):___________________________________

4. Date of birth:________________________________________________

5. What is the disability that prevents you from using the fixed route service?
____________________________________________________________
____________________________________________________________

Is this condition temporary? ____ If Yes, expected duration  ____

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

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

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