SweetHART Senior Application
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ADA Visitor Application ADA Visitor Transportation on SweetHART Individuals from outside the HARTransit service area will be served as ADA Visitors on SweetHART if they are unable to access the CityBus transportation services due to a qualifying disability. Eligible visitors will be served for a period of 21 days - during any 12 month period. NAME: ____________________________________________________________________ HOME ADDRESS:____________________________________________________________ APT#: __________ CITY: _______________________________ ZIP CODE: ______________ PHONE #:___________________________________ TDD/TTY: ______________________ BIRTH DATE: ______________________________ MALE FEMALE INDICATE IF YOU USE ANY OF THE FOLLOWING: WHEELCHAIR WALKER CANE SCOOTER NAME OF TRANSPORTATION PROVIDER THAT CERTIFIED YOUR ADA PARATRANSIT ELIGIBILITY: _________________________________________________________________________ PHONE #:____________________ CITY: __________________ STATE: ________________ ADDRESS YOU WILL BE VISITING (Within HARTransit service area): _________________________________________________________________________ APT#: __________ CITY: _______________________________ ZIP CODE: ______________ DATE OF REQUESTED SERVICE: ___________________ THROUGH: ___________________ EMERGENCY CONTACT PERSON: _______________________________________________ PHONE #:__________________________RELATIONSHIP: ___________________________ This application may be faxed, mailed or emailed to [email protected]. Do not send original documents to our office and make sure copies are legible. By submitting this from, you authorize HARTransit to contact the certifying district regarding your ADA status. Partially completed applications will not be accepted. 62 Federal Road, Danbury CT 06810 Tel: (203) 744 4070 Fax: (203) 744 0764 www.HARTransit.com
