8.17.22 OUTBoard Packet - Laserfiche WebLink

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Orange County Transportation Services ADA Paratransit Plan Orange County Planning Department Page 32 Person completing form other than applicant (please check one): ☐I certify that the information provided in this application is true and correct, based upon information given me by the applicant. ☐I certify that the information provided in this application is true and correct, based upon my own knowledge of the applicant’s health condition or disability. Name: Daytime Phone Number: Relationship to Applicant: Signature of Preparer: Date: I understand that the purpose of the application is to determine if I am eligible for Orange County Public Transit’s ADA complementary paratransit service. I certify that the information I gave in this application is true and correct and that the application are returned to me if not complete, which delays processing. I understand that falsification or misrepresentation of facts, or changes in my medical condition, may result in changes to my certification status. I further understand that additional information from my healthcare professional related to my disability or medical condition is required and are used to help determine my eligibility. I agree to notify Orange County Public Transit if I no longer need to use ADA complementary paratransit services. Signature of Applicant: _________________________________________ Date: _______________ (Applicants must be 18 years of age to sign independently. Otherwise, the signature of a guardian is required.) 42