NOTA Request Professional VerificationProfessional Name(Required) First Last Applicant Name(Required) First Last DOB_af_date MM slash DD slash YYYY THESE PAGES MUST BE FILLED OUT BY PROFESSIONAL North Oakland Transportation Authority (NOTA) requires verification by a professional 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. or mail to: 675 Glaspie Street, Suite AOxford, MI 48371Social Worker Social Worker Physician Physician PT/OT PT/OT Counselor Counselor Nurse Practitioner Nurse Practitioner Other Other If other is selected, please give additional info:Applicant DisabilitiesApplicant DisabilitiesTemp No Temporary No Temp Yes Temporary Yes Temp Disability End DatePlease Select All That May ApplyMotor Wheelchair Motor Wheelchair Walker Walker Wheelchair Wheelchair Service Animal Service Animal Cane Cane Leg Braces Leg Braces Crutches Crutches Power Scooter Power Scooter Other Other Blind Yes Blind Yes Blind No Blind No Cognitive Yes Cognitive Yes Cognitive No Cognitive No Exceed 400 lbs Yes Exceed 400 lbs Yes Give Address Yes Can Give Address Yes Give Address No Can Give Address No Give Address Sometimes Can Give Address Sometimes Landmark Yes Can Give Landmark Yes Landmark Sometimes Can Give Landmark Sometimes Landmark No Can Give Landmark No Change Yes Ok With Change Yes Change No Ok With Change No Change Sometimes Ok With Change Sometimes Follow Diections Yes Can Follow Directions Yes Follow Directions No Can Follow Directions No Follow Directions Sometimes Can Follow Directions Sometimes Explain ResponsesYour NameTitle/PositionLicense or ID numberName Of OrganizationOffice AddressAPT #StateCityZip CodeOffice PhoneTodays Date_af_dateSignature
