Greeley Evans Transit: Request for Recertification of ADA Paratransit Eligibility "*" indicates required fields Step 1 of 6 16% Your application requires a signed release form. Would you like to complete this form electronically? * Required Yes, I will complete it electronically at the end of this form No, I prefer complete a paper form and upload it Please upload your signed Release Authorization * RequiredPlease download our paper form, print and sign, and then upload your release. Max. file size: 5 MB.Maximum file size - 5 mega bytes. Name * Required Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Email * Required Enter Email Confirm Email Address * Required 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) * RequiredPhone (Work)Phone (Cell)Date of Birth * Required MM slash DD slash YYYY What method of communication works best for you to receive notifications? * Required Home Phone Cell Phone E-Mail Have there been any changes to your disability since last certification? Yes, Improved or Improving Yes, Declined or Declining No Change or Remaining the Same Unsure Please describe * Required 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 Cane Wheelchair Make and Model * RequiredWhat is the weight of your wheelchair with you in it? * RequiredBe 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) * RequiredLength of Chair (inches) * RequiredDo you require a Personal Care Attendant when you travel using transit? * Required Yes No Can you travel 200 feet without the assistance of another person? * Required Yes No Sometimes Can you travel 1/3 mile without the assistance of another person? * Required Yes No Sometimes What is the maximum length you can travel without assistance from another person? * RequiredCan you climb three 12-inch steps without assistance? * Required Yes No Can you wait outside without support for 10 minutes? * Required Yes No Sometimes Can you ride in a “sedan” type vehicle such as a taxi? * Required Yes No Contact PersonsPlease provide names and telephone numbers of up to three people that we may contact if the need arises.NamePhoneNamePhoneNamePhone ConfirmationIs this application being completed by someone other than the person requesting certification? * Required Yes No Person Assisting * Required First Last Address of Person Assisting * Required 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 * RequiredSignature of Person Assisting * RequiredSignature * RequiredBy signing you certify that the information given above is correct.Signature Name * RequiredPlease 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].CAPTCHAURLThis field is for validation purposes and should be left unchanged.
