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Applicant’s Name:

_______________________________________________________

ADA ID#:_____________________ Birthdate:__________________

ADA Eligibility:      Perm/Temp      Full/Cond: ___________________

How much taxi value do you have left over now? $______________

» Complete ALL the questions below and return this form to the SF Paratransit, 68-12th Street, 1st Floor, San Francisco, CA 94103-1297. Please call the Eligibility Department at (415) 351-7050 if you have any questions about this form.

» Your request will be processed within 5 working days.

» You will be asked to complete this form each time you request additional paratransit service.

» If you have Conditional Eligibility, your service request will be e reviewed based upon your eligibility conditions. Please refer below.

» Trips may be verified by the S.F. Paratransit Broker’s Office.

Please list all trips you need covered by Paratransit, indicate if regular/temporary.

 OriginDestinationOne-Way Trip Cost # Of Trips A Month Regular TripsTemporary Trips 
A.     
B     
C.     
D.     
E.     
F.     
G.     
H.     
I.     
J.     
K.     
L.     
M.     
N._________________________________      

FOR CUSTOMERS WITH CONDITIONAL ELIGIBILITY ONLY:

Your ADA DOCUMENTATION OF PARATRANSIT ELIGIBILITY issued on your SF Paratransit Debit Card states whether or not you are conditionally eligible for Paratransit Services.

Note: For all other trip conditions, the use of Muni Accessible Fixed Route Services is available. Please call (415) 701-4485 for further information on accessible routes.

For each trip requested listed from A to O, please state WHAT CONDITIONS PREVENT use of the Muni bus, streetcar, train, or BART.

A.________________________________________________________________________________________

B.________________________________________________________________________________________

C.________________________________________________________________________________________

D.________________________________________________________________________________________

E.________________________________________________________________________________________

F.________________________________________________________________________________________

G.________________________________________________________________________________________

H.________________________________________________________________________________________

I.________________________________________________________________________________________

J.________________________________________________________________________________________

K.________________________________________________________________________________________

L.________________________________________________________________________________________

M.________________________________________________________________________________________

N.________________________________________________________________________________________

O.________________________________________________________________________________________

When ALL questions are completed, please return form to the Paratransit Office in the enclosed envelope as soon as possible.

 

 

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