DRAFT ADA PARATRANSIT APPLICATION - Metro Transit

GENERAL INFORMATIONLast Name: __________________________________________________________________First Name: _______________________________________________ MI: _______________Address: ________________________________________________ Apt#: _______________City: ____________________________ State: _________ Zip: _______________Daytime Phone: (____) ______________________________ TTY: Yes NoEvening Phone: (____) ______________________________ TTY: Yes NoBirth Date: _______/________/________Gender: M_____ F_____Social Security Number: ____________--_________ -- ____________Current or previous Call-A-Ride ID card# ______________Expires (ed)________Do you need future written information provided to you in an accessible format?Yes___ No___ If YES: Please indicate your preferred format:____Computer Disc ____Audio Cassette ____Braille ____ Large PrintEmergency Contact Person:Name: _________________________________ Relationship: ____________________Day Phone: (____) ___________________ Eve. Phone: (____) ____________________Did anyone assist you with completing this form? ❒Yes ❒NoIf yes, please provide the following information about that person.Name____________________________________________________________Phone: (____) ___________________ Relationship: ______________________Revised: 11/29/10 3 of 10