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R-Transit Online Application

  1. Gender*

  2. Section I: Valid Identification & Proof of Residency

  3. idadd.JPG

  4. Upload an acceptable form of identification

  5. Upload proof of residency

  6. Section II: Emergency Contact Information

    Please provide a name and telephone number of a contact person in the event of an emergency.

  7. Section III

    Please answer the following questions - your specific answers to the questions will familiarize us with your individual needs.

  8. 3. How do you currently travel to your destinations? Check all that apply. *

  9. 4. Do you use any of the following mobility aids or specialized equipment? Check all that apply.

  10. Does your residence have a ramp to accomodate your wheelchair or scooter?*

  11. Does the wheelchair or scooter have a seatbelt?*

  12. Can your manual wheelchair be folded?*

  13. 5. Can you transfer into a vehicle with minimal assistance?*

  14. 6. Does a personal care attendant accompany you when you travel outside the home?*

  15. Section IV

    Age and Disability verification

  16. Proof of disability

    Applicants between the ages of 18-54 must provide proof of disability. Select the proof of disability you will provide:

  17. Upload a scan of your Medicare card in jpg format

  18. Upload a scan of your receipt in pdf or jpg format

  19. Upload a scan of your RTC card in jpg format

  20. Upload a scan of your certification with East Bay Paratransit in pdf format

  21. Upload your signed form in pdf format

  22. Upload the completed and stamped form in pdf format

  23. Applicant Certification*

    By checking the box and typing my name below, I am electronically signing my application. I understand all information will be kept confidential and only the information require to provide the services will be disclosed to those who perform the service.

  24. Leave This Blank:

  25. This field is not part of the form submission.