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   <br />  <br />ADA PARATRANSIT SERVICE APPLICATION <br /> <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 /> <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 /> <br />Step 1: Complete the General Information Section <br /> <br />Name: <br />Last _________________________ First ____________________ MI ___________ <br /> <br />Address: <br />Street _______________________ City ___________ State ______ Zip _______ <br /> <br />Phone: <br />Home _________________ Work __________________ Cell _______________ <br /> <br />Date of Birth: _______________________ <br /> <br />Step 2: Information about your disability <br /> <br />1. What disability prevents you from using Orange Public Transportation Fixed-Route Bus <br />Service? Please specify all that apply. <br /> <br /> <br /> <br />_________________________________________________________________________ <br /> <br />2. How does your disability prevent you from using Orange Public Transportation Bus <br />Service? <br /> <br />_________________________________________________________________________ <br /> <br />_________________________________________________________________________ <br /> <br />3. Please describe the area where you live (e.g., rural, urban, suburban, flat, very steep hill, <br />gradual hill, etc)? <br /> <br />_________________________________________________________________________ <br />24