Request for Professional Verification

Applicants Name*

THESE TWO PAGES MUST BE FILLED OUT BY PROFFESSIONAL North Oakland Transportation Authority (NOTA) 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) 693-7100.

1) What is your professional relationship to the applicant?*

2) What is/are the applicant’s disabilities/diagnosis?*

3) Is this disability temporary? If yes, until:*

4) Please list the mobility aid(s) that the applicant uses to your knowledge:*

5) Is the applicant legally blind?*

Yes
No

6) Does the applicant have a cognitive disability?*

Yes
No

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

Yes
No

8) Is the applicant able to?

a) Give address and telephone numbers upon request:*

Yes
No

b) Recognize a destination or landmark:*

Yes
No

c) Deal with unexpected change in routine?*

Yes
No

d) Ask for, understand and follow directions?*

Yes
No

Please explain any OTHER responses from question #8 above or describe any other effects of the disability not already provided elsewhere on this form

Professional's Name*

Title/Position*

Permanent Professional License/ID#*

Name of Organization*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

I hereby certify that the information given above and in this application is correct.

Professional's Signature*

Date of Signature*

Phone

This field is for validation purposes and should be left unchanged.

248-887-4979

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Request for Professional Verification

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