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Dear Dial-A-Ride Client, We are writing to inform you the Federal Transit Administration rules and regulations require us to certify the eligibility for the WTS Complementary Paratransit Service Program. This is a requirement for us to receive federal funds for the program. Without these funds the program would not be sustainable. We have enclosed a Paratransit Service Application and a Professional Verification form. Please take this form to your physician and ask that he or she complete it for you and mail it back to the WTS Complementary Paratransit Service Program in the envelope provided. Thank you for your time and effort in helping us satisfy this requirement. If you have any questions regarding this matter, please call me at [PHONE REDACTED]. Sincerely, Kathleen McClaskey, Transit Operations Manager City of Woodburn, Community Services Dept. 270 Montgomery St. Woodburn, OR 97071 [PHONE REDACTED] ---PAGE BREAK--- PARATRANSIT SERVICE APPLICATION FORM-Completed by rider First Name Last Name Email address Phone number Preferred method of contact Do you need a vehicle with a ramp or lift for some of all of your trips? Yes No Do you travel with a mobility aid when you take trips with paratransit? Yes No PROFESSIONAL VERIFICATION FOR COMPLEMENTARY PARATRANSIT SERVICE To be completed by agency representative or medical professional familiar with the applicant. Federal law requires that specialized, door -to-door service must be provided to persons who cannot use available fixed-route service due to a disability. To be eligible, persons must have a disability that prevents use of the Woodburn Transit fixed route bus service. All buses are equipped with wheelchair lifts and Woodburn Transit provides information on how to utilize the bus. 1. Name of Applicant: 2. Phone: 3. Name of Agency or Medical Office: 4. Name of Representative or Physician: 5. Telephone Number: 6. In what capacity do you know the applicant: ---PAGE BREAK--- 7. In your opinion is the applicant able to: Board or disembark from a transit bus without assistance Board or disembark from a transit bus within a reasonable amount of time Walk to a close transit bus stop Travel on the transit bus unassisted Climb three 10-inch steps 8. Is the applicant's disability permanent or temporary? I have reviewed this application and offer these additional comments: I believe that the information provided is true and correct. I understand that deliberately providing false information is punishable by law and may jeopardize the receipt of services. I hereby authorize the City of Woodburn and its agents and employees, to verify the information provided in this application. Signature of person completing form Name of person completing form (Please print) Date SIGN