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I agree that, if I am certified for Orange County Public Transportation ADA Paratransit, I will pay the exact fare, if required, for each trip. I agree to notify the office of any changes in my status that may affect my eligibility to use the service. I also understand that failure to adhere to the policies and procedures will be grounds for revoking my application and the right to participate in the program.
I understand and agree to hold Orange County and Orange County Public Transportation harmless against all claims or liability for damages to any person, property, or personal injury occurring as a result of my failure to equip or maintain the safety of the adaptive equipment or certified guide/service animal that I require for mobility.
I hereby authorize the release of verification information and any additional information to Orange County/Orange County Public Transportation for the purpose of evaluating my eligibility to participate in the Program.
I certify that the information provided in this application is true and correct.
As a requirement of the Americans with Disabilities Act of 1990 (ADA), Orange County Public Transportation is a federally subsidized public transportation service set aside for passengers who are prevented from using fixed -route service due to a mobility limitation. ADA paratransit service is not intended to include persons who find it inconvenient or even difficult to get to or from fixed-route bus stops. Disability alone is not an automatic qualifying determinant for ADA paratransit bus service. As a medical provider, you are uniquely familiar with the genera health and abilities of your patent. As such please provide answer to the following question as they relate to mobility limitations resulting from a functional or cognitive disability.
All information for verification of eligibility must be filled in by a qualified health care professional.
Please list the dates of duration.
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Once the completed form has been printed please mail in the form to our Administrative Office : 600 NC 86 Hillsborough, NC 27278 or
fax the form to (919) 732-2137
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