Revised January 2021

Page 2 of 2

I am currently eligible for Medical Assistance or Community Health Choices (check one

)

_____ Yes

_______ No

_______ Not Sure

Port Authority Bus Service You Will Use



Which Port Authority routes serve your neighborhood? _________________________________



Where is the bus stop closest to your home? _________________________________________



Why do you need ACCESS Connections Service? (Check as many as apply)

_____ The bus stop is more than ¾ mile from my home

_____ The bus stop is more than ¾ mile from my destination

_____ There is no bus service at the time I need to travel

_____ I have to take several buses, which takes me a long time

Trips you will take

Please list the three most common trips you would like to take.

Origin (Address)

Destination (Address)

Frequency

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Emergency Contact



Please provide the name and phone number for someone we should contact in case of an emergency

(optional):

___________________________________________________________________________________

Will you need future materials in an accessible format? (Circle):

Large Print

Word or Text file by e-mail

Audio Cassette

Braille

Signature (Required)

I certify that I have been truthful and that the information I have provided is accurate and correct.

_______________________________________________

___________________________________

Signature

Date

Submit your completed application along with proof of age and verification of your disability. Mail to ACCESS

Connections Program, 650 Smithfield St., Pittsburgh, PA 15222 or e-mail to ada@accesstransys.com

.