Gold Card Impairment Certification Form Page 2

Medical Professional Information:

Print Name ______________________________ Title _____________________________________

Signature ____________________________________________ Date ________________________

Address ___________________________________________________________________________

City ____________________________________________ State ____________ Zip ____________

Office Number ___________________________ Fax Number _______________________________

Email __________________________________ Medical License No. ________________________

If you have any questions, please call our office at (941) 861-1018.

Thank You

Please check that all information is provided and mail application to:

Sarasota County Area Transit

Attention: Mobility Coordinator

5303 Pinkney Avenue

Sarasota, Florida 34233-2421

Or Fax to: 941-861-1011

SCAT Gold Card Impairment Certifiaction Form

December 2013

Page 2 of 2

0 votes

Parent category: Business