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.
Address Line 1
Address Line 2
Directions to Home
Describe nature of disability (In your own words)
Is this condition temorary?
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?
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?
If yes, please explain
Do you have any special need, such as oxygen?
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.)
Powered scooter (3 wheeled)
Personal Care Assistant (PCA)
Other (Please Describe)
If you require a PCA, is it
Wheelchair/Scooter Users: What is the total weight of you and the chair?
If this application has been completed by someone other than the person requesting certification, that person must complete the following:
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