The information obtained in this certification process will be used by the FMCTA Eligibility Committee only for the provision of transportation services. Information will be shared only with other transit providers to facilitate travel in those areas. The information will not be provided to any other person or agency.

First Name

Middle Initial

Last Name

Age

Address Line 1

Address Line 2

City ,WV

Zip

Directions to Home

Home Phone

Other Phone

Describe nature of disability (In your own words)

Is this condition temorary? Yes No

If yes, date expected to end

How long have you had this disability?

Describe mobility (What prevents you from getting to or on a bus which has a wheelchair lift?)

How far do you live from a route bus?

Can you climb steps? Yes No

If yes, how many?

How high (each step)?

How long can you stand without assistance?

How far can you walk without assistance?

Does weather affect your condition in any way? Yes No

If yes, please explain

Do you have any special need, such as oxygen? Yes No

If so, please list

The following information will help us take the appropriate measures in providing service to you.
Do you use any of the following aids for traveling? (Check all that apply.)

Manual Wheelchair

Electric Wheelchair

Powered scooter (3 wheeled)

Cane

Crutches

Walker

Personal Care Assistant (PCA)

Assistance Animal

Other (Please Describe)

If you require a PCA, is it Always Sometimes

Wheelchair/Scooter Users: What is the total weight of you and the chair? LBS

Other Comments

If this application has been completed by someone other than the person requesting certification, that person must complete the following:

Name

Address

City

State

Zip

Relationship

Daytime Phone

Upon completing this application you are certifying that the information given herein is correct, and by checking below, you agree to abide by ADA rules.

Upon approval you will recieve a letter, riders card, ADA handbook, and a signature sheet that can be turned in with the driver on your first ride with us.

I have read and understand the above disclaimer