Mobility Bus Application Form

Please complete and submit the Applicant portion of this form. You will receive an email containing the Professional Certification portion which must be printed and completed by a Health Care Professional.

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First name

Last Name

Address

City

Postal Code

Primary Phone Number

Secondary Phone Number

E-Mail Address

Do you use: (check all that apply)

Wheelchair

Walker

Scooter

Cart

Crutches

Cane

Other

Regarding fixed route transit service – bus stops – please select one:

I can usually get to and from a regular transit stop without assistance

I can get to and from a regular transit stop only if: (Select all that apply)

I can never get to and from a regular transit bus stop (Please explain why)

APPLICANT DECLARATION

I hereby certify that to the best of my knowledge, the information given above is correct. I authorize the release of medical information to the City Of Belleville. I consent to the contents of my application and eligibility for specialized transit services discussed with the health care professional that completed part of this application.

Signature of Applicant or Designate

Clear

Date

The REQUEST FOR PROFESSIONAL CERTIFICATION portion must be filled out by an appropriate health care professional.

If your disability prevents you from using the City Of Belleville regular fixed-route transit service, one of the following health care professionals, as appropriate to your case, must complete the professional certification part of this application form: Licensed physician, Registered occupational therapist, Licensed physical therapist, Certified psychologist/psychiatrist, Licensed optometrist/ophthalmologist/eye physician, Registered Nurse.

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Mobility Bus Application Form

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APPLICANT DECLARATION

The REQUEST FOR PROFESSIONAL CERTIFICATION portion must be filled out by an appropriate health care professional.

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