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?*YesNo6) Does the applicant have a cognitive disability?*YesNo7) Does the applicant exceed 400 pounds? (Vehicle Lift Restrictions)*YesNo8) Is the applicant able to?a) Give address and telephone numbers upon request:*YesNob) Recognize a destination or landmark:*YesNoc) Deal with unexpected change in routine?*YesNod) Ask for, understand and follow directions?*YesNoPlease explain any OTHER responses from question #8 above or describe any other effects of the disability not already provided elsewhere on this formProfessional's Name*Title/Position*Permanent Professional License/ID#*Name of Organization*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*I hereby certify that the information given above and in this application is correct.Professional's Signature*Date of Signature* Date Format: MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.