Request for Professional Verification

This field is for validation purposes and should be left unchanged.
THESE TWO PAGES MUST BE FILLED OUT BY PROFFESSIONAL Western Oakland Transportation Authority (WOTA) requires verification by a professional in order to qualify disabled individuals requesting service for transportation. Please fill in all sections that pertain to the applicant’s disabilities as they relate to using public transportation. If you have any questions, please call (248) 887-4979.
5) Is the applicant legally blind?(Required)

6) Does the applicant have a cognitive disability?(Required)

7) Does the applicant exceed 400 pounds? (Vehicle Lift Restrictions)(Required)

8) Is the applicant able to?
a) Give address and telephone numbers upon request:(Required)

b) Recognize a destination or landmark:(Required)

c) Deal with unexpected change in routine?(Required)

d) Ask for, understand and follow directions?(Required)

Address(Required)
I hereby certify that the information given above and in this application is correct.
Professional's Consent(Required)
I am unable to use finger/mouse or file upload to sign and will only type my name in "Signature Typed" box below.
Clear Signature
Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 512 MB.
I choose to upload a digital version of my signature.
Date of Signature(Required)