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Personal Information

Mailing Address (If Different)

The Environment Around Your Home
Current Travel
List your four most frequent destinations and how you get there now:

DestinationFrequency of TravelHow You Get There Now
What is your disability?
(Disability is defined as a physical or mental impairment that substantially limits one or more activities.)

DisabilityReason / Cause of Disability
Physical Ability

The following set of questions pertain to your physical capabilities only.

Do you use any of the following aids for mobility? (Check all that apply)

Cognitive Conditions

Please mark all of the categories below as they relate to your disability. Can you:

Person to contact in case of emergency
Acknowledgement and Verification

Whoever knowingly and willfully falsifies or conceals a material fact, shall be fined not more than $10,000 or imprisoned more than five (5) years or both (18 USC Section 1001, 1982) Under penalty of law, I hereby certify that the information given above is correct.

If this application has been completed by someone other than the person requesting certification, please complete the following:

Please remember that the professional verification form must also be submitted before this application is considered complete and can be reviewed.