NOTA Application Passenger Information Web Site Full Name * Todays Date * Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Township * Home Phone Cell Phone * Email Address Age Date of Birth * Disabled? Disabled? Please Explain In case of emergency, please contact: * Emergency Contact Phone Companion Rider (18yrs+) Companion Rider Date of Birth Select All That Apply (Must Choose One) * Senior Citizen Disabled Person Low Income Qualified Resident Youth Companion Rider Service Animal Other None Low Income Qualified Level * Does Not Apply 1 Person In Household (Less or Equal $18,735) 2 Persons In Household (Less or Equal $25,365) 3 Persons In Household (Less or Equal $31,995) 4 Persons In Household (Less or Equal $38,625) 5 Persons In Household (Less or Equal $45,255) 6 Persons In Household (Less or Equal $51,885) 7 Persons In Household (Less or Equal $58,515) 8 Persons In Household (Less or Equal $65,145) NOTE: For each additional household member add: $6,240 Mobility Devices Wheelchair XL Wheelchair Scooter Walker NOTE: For Safety reasons, All Mobility Devices cannot be more that 33 inches wide and/or be more that 1,000 lbs including the Passenger while on the lift. Race (Optional) I, Type Full Name , have earned $ Amount Within the last 12 months. I have # of Family Members members in my family (include yourself) I am supporting. Included Drivers License I have included a copy of a Driver’s License, or other proof of residency with this form. Drivers License Upload * Certify Information True I certify that the above information is correct and the address is where I reside, And I understand that submitting false information is just cause for refusal of service.