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Orange County Transportation Services ADA Paratransit Plan 42 <br /> Travel distance limitations: <br /> Limitations regarding time of day to travel: <br /> Weather conditions: <br /> Environmental conditions: <br /> 5. Please choose the statement below which best represents your opinion regarding this individual's use of <br /> public transportation: <br /> ❑This individual should be able to access public transportation successfully. <br /> ❑This individual can use public transportation under certain situations as stated above. <br /> ❑This individual cannot use public transportation due to multiple functional limitations. <br /> Signature: Date Signed: <br /> Print Name: Print Title: <br /> Business Address: <br /> City: Zip: <br /> Phone: Fax: <br /> Organization/Practice: <br /> Type of Practice: <br /> THANK YOU FOR YOUR ASSISTANCE! <br /> FOR OCTS USE ONLY <br /> APPROVED❑ DENIED❑ <br /> ISSUED BY TITLE <br /> DATE FILE NUMBER <br /> Orange County Planning Department Page 36 <br />