Wheel-Chair Eligibility Certification Application Page 2
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3If you have a pare-transit I.D. Card from another agency, please provide agency’s name and I.D.
number ___________________________________________.
In case of emergency notify:
Name
Relationship
Home phone
Work Phone
Address
City
State
Zip
PART II – Information on disability
Is your disability permanent? _______
If not, expected duration of your disability __/__/__ (Note: Extension of a temporary disability
requires a new application to be submitted.)
Physician’s Name_______________________________ Office Phone_____________________
Address
City
State
Zip
PART III – Changes to my existing application (Check all that apply)
_____ Name Change
_____ Address Change
_____ Phone Number(s) Change
_____ Email Address Change
• Make changes to applicable information only.
• Read and sign the Affirmation in Part V. Notarization is NOT required.
• Mail completed form to address in PART IV.
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