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Name: Address: Cape May County Department of Transportation Certification Application (For Disabled Residents) Telephone: ( ) Date of Birth: / / Emergency Contact: Emergency Contact Telephone: ( ) Disability criteria Section # (please see list below) Permanent/Temporary: (Please circle one) Number of months if temporary: Is attendant care necessary while traveling?: Yes or No (Please circle one) Name of certifying Agency Director or Physician: Physician’s telephone number: ( ) Physicians license Applicant’s signature: Disabled Service Eligibility Criteria Physical Disabilities: Section # 1 Non ambulatory Disabilities Section # 2 Mobility aids Section # 3 Arthritis Section # 4 Amputation Section # 5 Cerebrovascular Accident (Stroke) Section # 6 Pulmonary Ills Section # 7 Cardiac Ills Section # 8 Dialysis Section # 9 Sight Disabilities Section # 10 Hearing Disabilities Section # 11 Disabilities of In coordination Developmental Disabilities Section # 12 Mental Retardation Section # 13 Cerebral Palsy Section # 14 Epilepsy Section # 15 Autism Section # 16 Neurological Handicap Mentally Disordered Disabilities Section # 17 Emotionally Disturbed Please return to: Cape May County Fare Free Transportation Department 4 Moore Road DN # 626 C.M.C.H., N.J. 08210