ADA Paratransit Recertification Form

Personal Information

Full Name Date of Birth Address City State Zip Code Phone Number Email

Disability Information

Please describe your disability or health condition Do you use a mobility aid or assistive device? None Cane Walker Manual Wheelchair Power Wheelchair Scooter Other If Other, please specify

Paratransit Usage

How often do you use ADA Paratransit services? Daily Weekly Monthly What types of trips do you use paratransit for?

Emergency Contact

Name Phone Number Relationship

Applicant Signature

Signature Date