Application for PARATRANSIT Service
Instructions: On pages 1 – 4 of this application, UCAT is asking for information about
you and your ability to use Paratransit bus service. Please take the time to answer
ALL questions carefully and completely. We cannot determine your eligibility for
Paratransit service without this information. A friend, guardian, caregiver, agency
service representative or family member may help you complete your portion of the
application, pages 1- 4. Accurate information is required about you, your medical
impairment, and your functional capacity. Pages 5 - 6 must be completed and certified
by a physician/certified health professional who is familiar with your impairment or
condition.
If you have questions, please call UCAT Customer Service at 845-334-8135.
Have you ever applied for Paratransit? No Yes
TO BE COMPLETED BY APPLICANT
Name of Applicant Last First Middle
Does applicant have Medicaid?
Address/Street
Apartment
City
Zip Code
Date of Birth
Home Phone Number
Other Phone
Apartment Complex Name
Gate Code
Mailing Address/If different from home address
City
State
Zip Code
Applicant Signature (required)
X
Date/
Name of Emergency Contact Relationship Emergency Phone
Date Received: __________
Date Entered: ___________
Processed by: ___________
Route Covered: _________
Paratransit Fare: _________
Shopper’s day: __________
