ADA Paratransit Service Application
This information is confidential and will not be released by the City of Annapolis Department of Transportation.
Applicant=s full name
Mail address
City ST Zip
Phone(s)
Resident (if applicable) City Anne Arundel County Other
Signature Date
To be completed by Physician / Service Professional (please print or type)
One or more of the following criteria must be identified for eligibility for reduced fare program:
Confinement to a wheelchair
Use of crutches, braces or walker
Inability to walk between bus stops (four blocks)
Inability to climb a bus step (15 inches)
Inability to stand waiting for a bus (15 minutes)
Inability to comprehend the service (route and fare)
Inability to travel without special facilities, assistance or escort - specify below
I certify that meets the City of Annapolis Transit
eligibility criteria and is permanently temporarily eligible for the identification pass.
Length of temporary disability (estimated number of months)
Name of physician Phone
Mail address
City ST Zip
FOR CITY USE ONLY
Approved Denied
Signature Date
City of Annapolis
Transportation Department
308 Chinquapin Round Road
Annapolis, MD 21401-4007
Transit@annapolis.gov410-263-7964410-269-0674Fax 410-269-5989 • TDD use MD Relay or 711 www.annapolis.gov
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