Fond du Lac Area Transit - Bus Routes for Fond du Lac, Wisconsin

Request for Certification of Americans with Disabilities Act
(ADA Paratransit Eligibility)

Americans with Disabilities Act (ADA) Public Transportation Rules

VERIFICATION is needed to certify that you are unable to use the regular fixed-route Bus Service and need to use specialized "curb-to-curb" paratransit service. Evaluation of your request will begin as soon as the form is completed and received. The information obtained in this request will only be used by the City of Fond du Lac and/or the Fond du Lac County for the provision of transportation services. Information will only be shared with other transit providers to facilitate travel in those areas and WILL NOT be shared with any other person or agency. You will be notified of our determination within 21 days after we receive your request. If you have any questions, call 929-3110, Fond du Lac County Senior Services.

Please fill out this form completely and click "submit".

Name:
Address:
City:
State:
Zip:
Date of Birth:
Telephone:	Home: Work:
Email:

The DISABILITY which prevents me from using the City "Bus Service" is:

Permanent   Temporary (if temporary, expected duration )

How does the disability prevent you from using the City "Bus Service"? (explain completely)

How far can you walk without the assistance of another person?
1 block
2-3 blocks
4-9 blocks
cannot walk without assistance

Is your ability to travel affected by extremes in the weather?
Yes    No
If yes, please explain:

Do you require a Personal Care Attendant?
Yes    No

Other effects or disability of which we need to be aware:

The following information will be used to ensure that an appropriate vechicle is utilized to provide your transportation and than an accurate analysis of your trip requrest can be made by the City of Fond du Lac/Fond du Lac County.

Do you use any of the following aids to mobility? (check all that apply)

Manual Wheelchair	Electric Wheelchair	Powered Scooter
Cane	Crutches	Guide Dog

By checking this box, I hereby certify that the information given above is correct.

If this request for certification has been completed by someone other than the person needing service, that person must complete the following.

Name:
Address:
City:
State:
Zip:
Telephone:	Home: Work:
Reason:
Email:

You may also print this page and mail to:
Fond du Lac County Senior Services Dept. - ADA
160 S. Macy Street
Fond du Lac, WI 54935

For more information call 929-3110.
T.D.D. for hearing impaired 322-3655

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PHONE DIRECTORY

920-322-3650 (24 hrs)
City of Fond du Lac