APPLICATION FOR PARATRANSIT SERVICES

The information obtained in this certification process will only be used by the Meridian Transportation Commission for the provision of transportation services. Information will only be shared with other transit providers to facilitate travel in those areas. The information will not be provided to any other person or agency.

NAME
ADDRESS
STATE
ZIP
TELEPHONE NUMBER

Home Work
DATE OF BIRTH
/ /
What is the disability which prevents you from using our fixed route service?

Is the condition temporary? Yes No

If yes, expected duration until / /

 

How does this disability prevent you from using the fixed route services? Please explain completely.
Are there any other effects of your disability of which we need to be aware?
The following information will be used to ensure that an appropriate vehicle is utilized to provide your transportation and that an accurate analysis of your trip requests can be mad by the Meridian Transportation Commission.
Do you use any of the following aids for mobility? (Check all that apply)

Manual Wheelchair
Electric Wheelchair
Powered Scooter
Cane
Crutches
Personal Care Attendant
Guide Dog
Walker
Do you require a Personal Care attendant when you travel using transit?

Yes No

Can you travel 200 feet without the assistance of another person?

Yes No

Can you travel 1 / 4 mile without the assistance of another person?

Yes No

Can you climb three 12 inch steps without assistance?

Yes No

Can you wait outside without support for ten minutes?

Yes No

I hereby certify that the information given above is correct.

Signed Date / /

If this application has been completed by someone other than the person requesting certification, that person must complete the following.

Name

Address

State

Zip

Daytime Phone

Signed Date / /