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36 <br /> ORANGE COUNTY <br /> NORTH CAROLINA <br /> ADA PARATRANSIT SERVICE APPLICATION <br /> If you have a physical or functional disability, as defined by the Americans with <br /> Disabilities Act (ADA), which limits you from using Orange Public Transportation's <br /> fixed-route accessible buses, you may be eligible for Orange Public Transportation ADA <br /> Paratransit service. The information obtained in this certification process will be used by to <br /> determine your eligibility. The information may be shared with other transit providers to <br /> facilitate your travel in other areas. <br /> This application must be filled out completely, including the verification of eligibility by a <br /> qualified professional. Incomplete applications will be returned to applicants. <br /> Step 1: Complete the General Information Section <br /> Name: <br /> Last First MI <br /> Address: <br /> Street City State Zip <br /> Phone: <br /> Home Work Cell <br /> Date of Birth: <br /> Step 2: Information about your disability <br /> 1. What disability prevents you from using Orange Public Transportation Fixed-Route Bus <br /> Service? Please specify all that apply. <br /> 2. How does your disability prevent you from using Orange Public Transportation Bus <br /> Service? <br /> 3. Please describe the area where you live (e.g., rural, urban, suburban, flat, very steep hill, <br /> gradual hill, etc)? <br />