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Section 1: Contact and General Information
Preferred Title
Mr.
Mrs.
Miss.
Ms.
First name
*
Middle name
Last name
*
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Name of Apartment Building, Complex, or Neighborhood
Email
Home Phone
Cell Phone
Birthday
*
Month
How do you prefer to receive information regarding your eligibility and ride?
*
Phone Call
Text Message
Other
Do you need information given to you in any of the following formats?
None
Large Print
Braille
Another Language
What is your living situation? Check all that apply.
*
I live alone
I live with a relative
I live with a non-relative
I live with a caretaker
Other
What is your type of residence?
*
House
Apartment/Condo
Group Home
Nursing Home
Assisted Living Facility
Supported Living Facility
Emergency Contact Information:
Name
*
Relationship
*
Home Phone
*
Cell Phone
Email
Is this the first time you have applied for ADA paratransit service?
Yes
No
Do you have a personal care attendant (PCA) who assists you with daily life functions?
*
Yes
No
Did you need help completing this form?
*
Yes
No
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