Request for Professional Verification PF - WOTA

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Please fill in the information below, sign and either email to: info@rideWOTA.org or mail to: 250 W. Livingston Rd. Highland, MI 48357.

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Request for Professional Verification

Request for Professional Verification

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Comments

This field is for validation purposes and should be left unchanged.

Applicants Name(Required)

Date of Birth

THESE TWO PAGES MUST BE FILLED OUT BY PROFFESSIONAL Western Oakland Transportation Authority (WOTA) requires verification by a professional in order to qualify disabled individuals requesting service for transportation. Please fill in all sections that pertain to the applicant’s disabilities as they relate to using public transportation. If you have any questions, please call (248) 887-4979.

1) What is your professional relationship to the applicant?(Required)

2) What is/are the applicant’s disabilities/diagnosis?(Required)

3) Is this disability temporary? If yes, until:(Required)

4) Please list the mobility aid(s) that the applicant uses to your knowledge:(Required)

5) Is the applicant legally blind?(Required)

Yes

No

Other

6) Does the applicant have a cognitive disability?(Required)

Yes

No

Other

7) Does the applicant exceed 400 pounds? (Vehicle Lift Restrictions)(Required)

Yes

No

Other

8) Is the applicant able to?

a) Give address and telephone numbers upon request:(Required)

Yes

No

Other

b) Recognize a destination or landmark:(Required)

Yes

No

Other

c) Deal with unexpected change in routine?(Required)

Yes

No

Other

d) Ask for, understand and follow directions?(Required)

Yes

No

Other

Please explain any OTHER responses from question #8 above or describe any other effects of the disability not already provided elsewhere on this form

Professional's Name(Required)

Title/Position(Required)

Permanent Professional License/ID#(Required)

Name of Organization(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

I hereby certify that the information given above and in this application is correct.

Professional's Consent(Required)

I agree to using an electronic signature.

By mouse/finger signing, file upload and/or typing my name below, I agree to using an electronic signature.

I am unable to use finger/mouse or file upload to sign and will only type my name in "Signature Typed" box below.

Yes

Professional's Signature(Required)

I am uploading my signature instead of finger/mouse signing.

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 512 MB.

I choose to upload a digital version of my signature.

Typed Professional's Signature(Required)

Date of Signature(Required)

Month

Day

Year

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