Online – Request For Professional Verification Form

Professional's Name

Applicants Name

Date Of Birth

THIS FORM MUST BE FILLED OUT BY PROFESSIONAL

North Oakland Transportation Authority (NOTA) requires verification by aprofessional 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.

What Is Your Professional Relationship to the Applicant?

Is This Disability Temporary?

Yes No

If Yes, Specify Until Date

Please check the mobility aid [s] that the applicant uses to your knowledge

Power Scooter

Other

If Other, Please Specify

Is the Applicant Legally Blind?

Yes

Does the Applicant Have a Cognitive Disability?

Yes

Does the Applicant exceed 400 Lbs? (Bus Lift Restriction)?

Yes

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

YOUR NAME

TITLE/POSITION

PERMANENT PROFESSIONAL LICENSE/ID#

NAME OF ORGANIZATION

OFFICE ADDRESS

APT #

CITY

OFFICE PHONE

STATE

ZIP

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

I Agree

Professional Signature (Please Type Full Name)

Date