Application for Paratransit Services ADA ... - Lake County

SECTION 1 – GENERAL INFORMATION New Recertification Female MalePLEASE PRINTLast Name: ________________First Name:Middle InitialDate of Birth: __________Social Security No.: _________________Medicaid No: ______________________Street Address:Apt. No: ______City: __________________________ State: ________ Zip Code: ____________Subdivision or Apartment Name: ________________________________If this is a “gated community” please provide the gate code: _________________Nearest intersecting street: ___________________________________________Mailing Address if different than above:City: __________________________ State: ________ Zip Code: ____________Home Phone:Work Phone:Cell Phone:Email:Please provide information for someone we can contact in case of an emergency:Name:Home Phone:Relationship: _____________________Cell Phone:Do you require materials or correspondence in an alternative format?_____Yes _____NoIf yes, please list acceptable formats:Lake County Board of County Commissioners and our Operator, MVTransportation, Inc. collects your social security number for the followingpurposes: identification and verification, billing and payments and benefitprocessing. Social security numbers are used as a unique numeric identifier andmay be used for search purposes.ADA ApplicationRevised 6/23/10