M.I. _____

2.  Address _______________________________________________________
   
     City ___________________________     State ______   Zip Code __________
            (IF RURAL ADDRESS - PLEASE SEND DIRECTIONS)

3.  Telephone Number (Home) (_____)_____________

     (Work) (_____)____________

4.  Date of Birth _____/_____/____ Social Security # ____________________

5.  What is the mental or physical disability that prevents you from using our fixed route
bus service? (Note: not an architectural (building), curb or landscape Barrier)
    ___________________________________________________________________
    ___________________________________________________________________

___________________________________________________________________   
    Is this condition temporary? _____ If yes, expected duration until ___/___/_____.

6.    How does this disability prevent you from using fixed route service?
       Please explain completely. Use an additional sheet if needed.
   
___________________________________________________________________
    ___________________________________________________________________

7.    Are there any other effects of your disability of which we need to be made aware?   

___________________________________________________________________    
___________________________________________________________________

Note: If the person requesting certification in Question # 1 is 65 years of age or older, please attach a copy of one of the following as required by the Pennsylvania 203 Lottery-Funded Transportation Program: Birth Certificate, Baptismal Certificate, Statement of Age from the Social Security Administration, Passport, Naturalization Papers, PACE ID Card, Driver's License, State Photo ID Card, Veterans Universal Access ID or Resident Alien Card.

THE FOLLOWING INFORMATION WILL BE USED TO ENSURE THAT AN APPROPRIATE VEHICLE IS UTILIZED TO PROVIDE YOUR TRANSPORTATION AND THAT AN ACCURATE ANALYSIS OF YOUR TRIP REQUEST CAN BE MADE BY THE BERKS AREA READING TRANSPORTATION AUTHORITY.

8.     Do you use any of the following aids to mobility? (CHECK ALL THAT APPLY.)
        Manual Wheelchair q        Electric Wheelchair q        Powered Scooter q
        Cane q      Crutches q      Walker q    Guide Dog   q

9.    Do you require a Personal Care Attendant when you travel using transit?
      (Please remember that BARTA Special Services provides door-to-door service only.)
       Yes q         No q         Sometimes q

10.  Please answer the following questions:

      Can you travel 200 feet without the assistance of another person?
      Yes q          No q         Sometimes q

      Can you travel 1/4 mile without the assistance of another person?           
      Yes q          No q        Sometimes q

     Can you travel 3/4 mile without the assistance of another person?
     Yes q          No q         Sometimes q

     Can you climb three 12-inch steps without assistance?
     Yes q          No q         Sometimes q

     Can you wait outside without support for ten minutes?
     Yes q          No q         Sometimes q

11.  If the client has Medical Assistance (ACCESS), please complete the following:

          Recipient #____________________________________________

          Card Issue #___________________________________________

      If enrolled in the Health Choices Program, please list the Managed Care

      Organization: ____________________________________________

In order to allow the Berks Area Reading Transportation Authority (BARTA) to evaluate your request, it may be necessary to contact a physician or other professional to confirm the information you have provided.  Please complete the following information and authorization form.  

12.  The following   (Check One)
       Physician q        Health Care Professional q       Rehabilitation Professional q
       is familiar with my disability and is authorized to provide information to the Berks
      Area Reading Transportation Authority (BARTA that is required to complete this
      certification.

    Name _________________________________________________________

    Address _______________________________________________________

    City ___________________________ State_______ Zip Code ____________

    Phone Number (_______)_______________________________

13.  If this application has been complete by somone other than the person requesting
       certification, that person must complete the following:

    Name _________________________________________________________

    Address _______________________________________________________

    City ___________________________ State_______ Zip Code ____________

    Daytime Phone (_______)_______________________________

    Signature ___________________________ Date _____/______/_______

14.  Print Name of Person Requesting Certification:
      (Same as Question # 1.)

    Name ________________________________________________________

    Date of Birth __________/_________/__________

    Signature _____________________________________________________

    Date ___________/____________/_____________

15.  I hereby certify that the information given above is true and correct to the
       best of my knowledge.

    Signed _______________________________ Date ____/_____/______

PLEASE COMPLETE ALL PAGES OF THE APPLICATION.  APPLICATIONS THAT ARE NOT COMPLETED PROPERLY WILL NOT BE PROCESSED.

RETURN COMPLETED FORMS TO:

BARTA
1700 North 11th Street
Reading, PA 19604-1599
Phone - 610-921-2361
Fax - 610-921-0209