AAR Applications ADA TRANSPORTATION ASSESSMENT

1 New york city TransitAARA pplicationsMTA NYCT-Paratransit130 LivingstonStreetBrooklyn,NY11201 ADA TRANSPORTATIONASSESSMENTAPPLICATIONoNew ApplicationoRecertification:IDNumber_Est e formularioesta disponibleenespano!.Si deseaobtener esteformulario,sirvase en lIamar alsiguientenumero de telefono1-877-337-2017oprimanumero "1".MTA New york city transit 's paratransit service,Access-A-Ride, provides origin-to-destinationtransportationwithi n New york Cityon anadvancereservation basisto persons who, becauseof a physical ormental disability, are unable to use public transitbusesor complete a questiondoesnot apply to you, pleaseclearly mark N/A in the space any questions whilecompleting this application,pleasecall1-877-337-2017and when the recordedmessage beginspress" 1.

2 " Ifyouare unable to complete theformyourself, itcan be completedby anyoneyouchoose to to3weeksto issued,an Access-A-Ride paratransit service card expiresthree(3) years fromthe date itwas issued,unless otherwise of theinformation you provide will be used solelyfor the purpose of determiningyour eligibility, and anyspecialassistanceyou may need that you submittwo(2)recent photographs (measuring2"in lengthx11Jz"in width and takenwithin the last threeyears) with this application for your identification your name on the back of each applicationwill not be processed unless the photographs areincluded. The photographsmust have asolid background andshow a full frontview of one:0 LargePrintDE-Mail-'--oAudio TapeoBrailleFor additionalinformation,contact Access-A-RideCustomerInformationat:877-3 37-2017 Toll free from area codes212,646, 718,347,516,631, 914,845718-393-4999 From all otherareacodes718-393-4259 TTY2"Do you need informationgiven to you in analternateformat?

3 11/2"..AddressAAR ApplicationsMTA NYCT-Paratransit130 LivingstonStreetBrooklyn,NY11201 ForOffice Use OnlyApplic. #:Subs. #:Date Entered:_By:_oOutreach0 Advertisement0 Other-----Completedapplicationsshould be returned to:AGREEMENT TO ELIGIBILITY TERMSANDCONDITIONS(ALL APPLICANTS MUST SIGN THIS AGREEMENT)I understand thatmy application will bereturned if it is not understand thatMTA NYCT ransit reserves the right to request additional proofof my disability or myinability to use public may include anevaluation at theoffices of a professionalcertifier selected affirm that all of the information thatI provide onthis application is trueto the best of myknowledge.

4 I understandthat my application is subjectto review and verification, including verification after myAccess-A-Ridecard has beenissued, andthatmisrepresentation of any materialinformationwill leadto revocation of my agree to notify NYCT ransit at 1-877-337-2017 if I nolongerneedparatransit servicefor any reason,includinga changein my ability to use bus and subway also understand thatmy failure tocooperate with a requestfor additional informationto verify statements made on myapplication after myAccess-A-Ride cardhas been issued will be groundsfor suspension or revocationof myeligibility in thisprogram. I furtherunderstand that my failure to adhere to the policies and procedures forusingAccess-A-Ride are also grounds forsuspension or revocation of my eligibility in this 's SignatureDateIf someone otherthan the applicant hascompleted this application,please provide the followinginformation:NameRelationship to ApplicantTelephone NumberDateREQUIRED IDENTIFICATION INFORMATION (PLEASE PRINT CLEARLY)LastNameFirst Code~~~~and---------------------CrossStr eetsHome TelephoneNumberWork TelephoneNumberE-mail AddressCellPhone NumberSex:---Date of BirthMaleFemaleIf your home addressis different from yourmailing addressand/or you have Box, pleasecompletethefollowing.

5 (Otherwiseleave blank)Street CodePersonto Contact in Caseof Emergency: (This section must be completed.)Last TelephoneNumberRelationship to Applicant:_Work Telephone NumberAPPLICATION have youbeentraveling within thelast 6 months?(Check all that apply)oPublic TransitBus0 Subway0 SchoolBusoWalking0 AutomobileoAccess-A-Ride0 CommuterRailroadoAmbulette0 Taxi/CarServiceoOther:__2. Are youregisteredwiththeMTA Reduced-Fare program?DYes0 a MetroCard?(Checkall thatapply)oYes, Iusemy MetroCard when traveling by busoYes,I use my MetroCardwhentraveling bysubwayoNo,I don't have a MetroCard4. Is your disability:oPermanent0 Temporary0 I don't know5. If temporary,please indicate how long you believe thetemporary disability will months0 3 months 0 6 monthsoOther(Specify) whichsupport device(s) you use when travelingor walkingoutside your donot requirea support Tank0 Walker0 BracesoSupport Cane0 Scooter*0 CrutchesoProsthesisoServiceAnimal(an animal that providesassistance)oManual Wheelchair*oMotorized Wheelchair*oOther(Specify) you have a serviceanimal, indicate the tasks(s)yourserviceanimal (visionimpairment)oAlertsme (hearing impairment)oPulls me (manual wheelchair)oCarries items for me(explainhow:)oOther(Specify):8.

6 Haveyoureceived training to use publictransitbusesorsubways?oYes0 No0No,I would liketrainingoI amin thetraining be able to travel by bus orsubway ifAccess-A-Ridetookyou from:(Checkall thatapply)oyour hometo abusstopothebusstopto yourhomeoyourdestination back to the bus stopoyourhometo an accessible subway stationothe accessiblesubwaystation to your homeoyourdestinationbackto the accessiblesubway stationoNot your home is the nearest publictransit busstop?oLess than1block 01to2blockso3 to 4 blocks05 or moreblocksIdentify location ofpublic transit bus doesit takeyou to walk to the nearestpublic transit bus stop?oLess than 5 minutesoMore than own orusing a supportdevice,are you abletogetto and from the public transit busstop nearest your home?

7 DYes0 NooSometimes-describethecircumstances:12 . On your own or using a supportdevice, canyougeton, ride, and get off3public transitbus when the"lmeeler" islowered(3kneeler is a devicethat lowersthe front of the bus)?DYes0 NooSometimes-describethe circumstances:*The AAR vehicles can onlyaccommodate awheelchairor scooterthatdoes not exceed30inches in width and48 inches in length and doesnotweigh morethan600pounds when How often do you travel on publiCtransit buses?oDaily0 Weekly0 MonthlyoOccasionally0 NeverIf you have used a public transitbusin the past, whendid you stop?( )Why did you stoptraveling by public transit bus?14. If you cannot walkup the stepson a busor use thekneeler, are you able to usethebuslift?

8 (Please note thatpersons whocannot climb thebus steps have the right to enter thebusbystanding on the lift.)DYes0No0 SometimesoDon't Know15. Are youable to identify and understand the destinationand route number signs on public transit buses?DYes0 NooOnly whenthe Bus Operator announces themoSometimes-describethe circumstances:16. Are you able to determine when you havereached yourdestination to getoff thepublic transit bus?DYes0 NooOnly when the Bus Operator announcesthe stopoSometimes- far from your home is the nearestsubway station?oLessthan 1block01 to 2 blockso3to4blocks0 5or more blocksIdentify locationof does ittake you to walk to thenearest subwaystation?

9 OLessthan5minutesoMore than 10 minuteso5-10 minutesoNot sure18. On yourownor using a support device, are you able toget toand fromthe subwaystation nearest your home?DYes0 NooSometimes-describethe circumstances:19. On yourownor using a support device, can you rideon an escalator?DYes0 NooSometimes-describethe circumstances:20. On your own or usinga support device, are you able to goto and from the station platform and the street entrance?DYes0 NooSometimes-describethe circumstances:oOnlyifequippedwith an elevator21. On your own or using a support device, howfar canyou travel on level street? Please answer in city On your own or using a support device,can youget on,rideand get off a subway train?

10 DYes0 NooSometimes-describethe circumstances:23. Areyou ableto determine surfaces (platform, top orbottom of stairs) in a subway station?DYes0 NooSometimes-describethe circumstances:24. Areyou able to identify and understand the destinationandsubway line signs?DYes0 NooSometimes-describethe circumstances:25. Areyou able to determine when you havereached yourdestination to get off the subway?DYes0 NooSometimes-describethe circumstances:oOnly whenthe Conductor announcesthe stop26. How often doyou travel using thesubway?oDaily0 Weekly 0 Monthly 0 OccasionallyoNot atAllIf youhave used the subway in the past, when did youstop using it?( )Whydidyou stop traveling by subway?