HomeServicesADA Paratransit EligibilityRecertify ADA Paratransit EligibilityRequest for Recertification of ADA Paratransit EligibilityStep 1 of 616%CAPTCHAYour application requires a signed release form. Would you like to complete this form electronically?* Yes, I will complete it electronically at the end of this form No, I prefer complete a paper form and upload itPlease upload your signed Release Authorization*Please download our paper form, print and sign, and then upload your release.Max. file size: 5 MB.Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Home)*Phone (Work)Phone (Cell)Date of Birth* MM slash DD slash YYYY What method of communication works best for you to receive notifications?* Home Phone Cell Phone E-MailHave there been any changes to your disability since last certification? Yes, Improved or Improving Yes, Declined or Declining No Change or Remaining the Same UnsurePlease describe*The following information will be used to ensure that an appropriate vehicle is utilized to provide your transportation and that an accurate analysis of your trip requests can be made by Greeley Evans Transit.Do you use any of the following aids for mobility? Check all that apply Wheelchair Cane Walker Service Animal Crutches White CaneWheelchair Make and Model*What is the weight of your wheelchair with you in it?*Be sure to give use the total weight. That is the weight of yourself added to the weight of the chair.Width of Chair (inches)Height of Chair (inches)*Length of Chair (inches)*Do you require a Personal Care Attendant when you travel using transit?* Yes NoCan you travel 200 feet without the assistance of another person?* Yes No SometimesCan you travel 1/3 mile without the assistance of another person?* Yes No SometimesWhat is the maximum length you can travel without assistance from another person?*Can you climb three 12-inch steps without assistance?* Yes NoCan you wait outside without support for 10 minutes?* Yes No SometimesCan you ride in a “sedan” type vehicle such as a taxi?* Yes NoContact PersonsPlease provide names and telephone numbers of up to three people that we may contact if the need arises.NamePhoneNamePhoneNamePhoneConfirmationIs this application being completed by someone other than the person requesting certification?* Yes NoPerson Assisting* First Last Address of Person Assisting* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of Person Assisting*Signature of Person Assisting*Signature*By signing you certify that the information given above is correct.Signature Name*Please type your full nameUpon submission you will be redirected to the release form that must be completed along with your application.A copy of your entry will be sent to the email that you provided. If you have questions, please contact GET at 970-350-9290 or email [email protected].PhoneThis field is for validation purposes and should be left unchanged. 99383
