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.
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 .
WE LOOK FORWARD TO SERVING YOU.