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Date:_______________________________ (If unable to sign, please see below)

NOTE:  If only able to make a “mark” for your signature, simply make your mark and then have someone act as a witness by signing their name above or beside yours.

IF SOMEONE ELSE HAS FILLED-OUT THIS APPLICATION FOR YOU PLEASE

HAVE THEM COMPLETE THE FOLLOWING:

The information provided in this application is based upon:

Information given to me by the applicant.

My own knowledge of the applicant’s current disability and health condition.

Signature:______________________________________________ Date:______________

Relationship to Applicant:_____________________________________________________

Daytime Telephone Number:__________________________________________________

THANK YOU FOR TAKING THE TIME TO FAMILIARIZE YOURSELF WITH THE INFORMATION IN THIS PACKET.  IF YOU HAVE ANY FURTHER QUESTIONS ABOUT OUR PARATRANSIT SERVICE YOU MAY CALL 540-982-2222.

WE LOOK FORWARD TO SERVING YOU.

Page 10

Revised 6/14/07

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