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Client Certification Form

2. 

4. Name

5. Email Address

7. Address

9. City

10. State

11. Zip Code

13. Phone Number

14. Date
    Date

15. Date of Birth
    Date of Birth

16. Sex

    1. Male
    2. Female

    Please select an option

18. Emergency Contact Information

20. Name

21. Relationship

23. Address

25. City

26. State

27. Zip Code

29. Phone Number

31. Please Select the service(s) that you are applying for:

    1. Elderly/Disabled (EdTap)
    2. Senior Transportation (Dept on Aging)
    3. Rural Generl Public (RGP)

    1. ADA (paratransit service)
    2. Employment (Workfirst)
    3. DSS Medicaid (NEMT)

    Check all that apply

33. ADA (paratransit service)
    ADA Paratransit Service Application

    If you select the ADA (paratransit service) please complete ADA form linked above. If sleceted ADA and another service please fill out both forms.

35. Medical Equipment

    1. Oxygen
    2. Wheel Chair
    3. Scooter
    4. Walker
    5. Service Animal

    Select all that apply

37. Mobility Status

    1. Ambulatory
    2. Non-Ambulatory

    Please select the option that applies to you

39. Care Attendant

    1. Yes
    2. No

    Please select the options that applies to you

41. Passenger Responsibilites
    Make reservations for transportation service a minimum of two business days prior to date of appointment; transit service requests must be made between 9:00 AM - 3:00 PM. Return service to go home must be called into OPT Dispatch at (919) 245-2008; YOU MUST BE READY AND AVAILABLE TO BOARD THE BUS AT 4:30 PM. There is no transit service provided after 4:30 pm.

    Make reservations for transportation service a minimum of two business days prior to date of appointment; transit service requests must be made between 9:00 AM - 3:00 PM. Return service to go home must be called into OPT Dispatch at (919) 245-2008; YOU MUST BE READY AND AVAILABLE TO BOARD THE BUS AT 4:30 PM. There is no transit service provided after 4:30 pm.

43. Instructions for Submission
    This application can be submitted online with the option of receiving a copy by email. You can also print out the application and submit it by mail or fax to our Administration Office. Mailing Address: 600 NC 86 Hillsborough, NC 27278 Fax Number: 919-732-2137

    This application can be submitted online with the option of receiving a copy by email. You can also print out the application and submit it by mail or fax to our Administration Office. Mailing Address: 600 NC 86 Hillsborough, NC 27278 Fax Number: 919-732-2137

45. Client Signature

    Please type your First and Last Name in the section above.

46. Processing Consent

    1. Agree and Consent

    By checking this box you consent to Orange County Public Transportation processing your application.

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field