In signing this application, the applicant agrees to the following conditions:
1) An interview will be required in addition to a completed application.
2) If at any time the applicant no longer has the disability as described, their
eligibility for paratransit services automatically ceases and they will no longer be
eligible to use Metro Mobility service.
3) Falsification of information in this application will result in a denial of service.
4) All information provided in this application will be kept confidential. Only the
information required to provide the services the certified individual requests will
be disclosed to those who perform those services.
5) An individual who is found ineligible for Metro Mobility services may appeal the
decision within 60 days of a written determination, and they will be advised of the
appeals procedures.
A. Applicant Signature
I certify the information given in this application is true and correct. I authorize
Metro Mobility to contact by phone or by letter any agency or professional that I
have indicated on this form in order to verify documentation of my functional
ability.
Applicant Signature:
_______________________________
Date: _____________
B. Person completing form if other than applicant (please check one):
I certify that the information provided in this application is true and correct,
based upon information given to me by the applicant.
I certify that the information provided in this application is true and correct
based upon my own knowledge of the applicant’s health condition or
disability.
Name:
_________________________________
Phone: _____________________
Relationship:
______________________________
Signature:
_______________________________________
Date: _____________
Please return this application in one of the following ways:
Mail: 1015 Transit Drive, Colorado Springs, Colorado 80903
Email: metrocertifications@springsgov.com
Fax: 719-385-5419
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