This application will be used solely to determine Demand Response eligibility for Franklin Regional Transit Authority. Transportation is curb-to-curb and service may be limited depending on where you reside. Please complete this application to the best of your ability. Please note that a determination of your eligibility will be made by the FRTA within one week of receipt of this completed application. Faxed copies will not be accepted.

PLEASE PRINT OR TYPE

LAST NAME:FIRST NAME:MI:

STREET ADDRESS:APT.

MAILING ADDRESS (IF DIFFERENT):

CITY OR TOWN:ZIP:

TELEPHONE:DATE OF BIRTH:

Please give us the name and telephone number of someone we can call in the event of an emergency.

Name:Telephone Number:

Relationship to you:

Please complete the following to see if you meet the criteria for Demand response Transportation.  Circle all options that apply:

1.   I am a FranklinCounty Home Care client (this information will be verified with FCHCC)

2.   I am 60 years old or older (please attach proof of age such as drivers license, photo ID card etc.)

3.   I currently reside in a nursing home facility.  Please indicate the duration of your stay _________

4.   I am a Veteran with a disability rating of 70% or greater (please attach a letter from the VA, signed by a Veterans Services Officer specifying your disability rating)

> Please indicate what type of mobility device is used (if any):

WheelchairCane Walker Other

I hereby understand that in order to be eligible to use Demand Response service, I must meet the above criteria. I agree that if any of the information given to the FRTA is materially false or misleading, the FRTA shall have the right to reconsider my eligibility for services. I certify that the information given above is correct.

SIGNED:____________________  DATE:______

If this application is being filled out by someone other than the person requesting certification, please complete the following:

Name

Relationship to applicant

Phone #

Signature

Once you have been determined eligible for services based on the above information, the FRTA will notify you in writing within one week of receipt of this application with instructions on how to utilize our service and book your trips.

FRTA 474 Main St., Greenfield, MA 01301

Revised August 2010