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Part 2. Applicant’s Certification

Please indicate below the reasons why you are seeking paratransit eligibility (check all that apply):

I can use Palm Tran fixed-route buses to go some places, but in other places I cannot get to or from the bus stops.

I can use Palm Tran fixed-route buses sometimes, but only if they are equipped with wheelchair lifts.

Because of my disability, I can NEVER use the Palm Tran fixed-route bus service.

I understand that the purpose of this form is to determine if there are times when I cannot use the fixed-route bus service provided by Palm Tran and must therefore use the van/shared-ride paratransit service.

I understand that the information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I certify that, to the best of my knowledge, the information in this evaluation form is true and correct.

I authorize the medical doctor who provided medical verification to release information relating to the disability to Palm Tran CONNECTION eligibility department.

In the event of a mandatory evacuation order by emergency management (such as during a hurricane or flood), would you need assistance to be evacuated?

Yes No

Applicant’s Signature:

Date:

______________________________________

________________

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