Wheel-Chair Eligibility Certification Application printable pdf download

Wheel-Chair Eligibility Certification Application

Office use only

PATH NO_________

Exp. Date_________

Port Authority Trans-Hudson Corporation

1 PATH PLAZA, 10

FL.

JERSEY CITY, NJ 07306

(800) 234-7284

ADA PARATRANSIT WHEEL-CHAIR ELIGIBILITY

CERTIFICATION APPLICATION

This certification form will be used to determine your eligibility for Port Authority Trans-Hudson

Corporation (PATH) para-transit wheel-chair transportation services (hereinafter referred to as

“para-transit services”). Para-transit Services is a station-to-station transportation service for

individuals with disabilities who utilize wheelchairs and are therefore prevented from using

PATH’s Grove Street Station, Jersey City, NJ.

You must complete the entire form. Answer every question. Incomplete forms will be

returned. A physician must verify your disability, prognosis and date of occurrence.

Verification can be obtained directly from your physician or from an agency that has record of

the physician statement on file. This information must be submitted with the application and

on the enclosed form. The information you provide is confidential. It will only be shared with

persons involved with PATH’s eligibility determination process, and will not be provided to any

other person or agency, except as provided by the New York Freedom of Information Law and

New Jersey's Open Public Records Act.

PART I – General Information to be completed by applicant

(please print or type)

Last Name

First Name

Mid. Initial

Gender

Social Security #

Date of Birth

Street Address

Building/Apt. No

Apartment Name

City or Town

State

Zip

Home Phone

Work Phone

Cellular Phone

Wheel-Chair Eligibility Certification Application