Wheel-Chair Eligibility Certification Application (Page 3 of 3) in pdf

Wheel-Chair Eligibility Certification Application Page 3

PART IV – Mailing address:

Port Authority Trans-Hudson Corporation

Attention: Operations Support Division

One PATH Plaza, 10

Floor

Jersey City, NJ 07306

PART V – Affirmation

I verify that all statements are true and correct to the best of my knowledge. I understand that

supplying false information can disqualify my application and/or subsequent registration. I

authorize PATH to obtain verification of any information given in this application and to obtain

essential medical information necessary for determination of para-transit eligibility. I also

agree to submit myself for an in-person evaluation by PATH and/or its acting agency for

determination of para-transit eligibility.

Applicant’s Signature

Date

If completed by someone other than applicant:

Name

Relationship

Date

Signature

Date

Notary Public:

State of_____________________________

County of___________________________

On this _____ day of __________, 20____,

Before me personally appeared

_________________________

to me known and known to be the same person (or legal guardian of the person) who is

described in and who executed the foregoing instrument, and he/she has duly acknowledged to

me that he/she has executed the same.

Notary Seal

Wheel-Chair Eligibility Certification Application Page 3