X hits on this document

35 views

0 shares

0 downloads

0 comments

9 / 11

Is there anything else you want to tell us about the applicant’s disability or health information that might help us better understand the applicant’s travel abilities and limitations?

PROFESSIONAL VERIFICATION

I understand that the purpose of this application is to determine if the applicant is eligible to use ADA Paratransit Services.  I certify that the information provided in this application is true and correct.  I understand the falsification of the information may result in denial of service to the applicant.  I understand that all information will be kept confidential.

Professional’s Signature:

Print Name:

Title:________________________________________ Date:____________________

Organization:

APPLICANT’S SIGNATURE

I certify that the information in this application is true and correct and I understand that giving false or misleading information may result in denial of ADA Paratransit Services.  I understand that all information will be confidential to the extent possible, and used to determine my eligibility for paratransit services.

Applicant’s Signature:________________________________________________________

Page 9

Revised 6/14/07

Document info
Document views35
Page views35
Page last viewedFri Dec 09 10:02:19 UTC 2016
Pages11
Paragraphs199
Words2245

Comments