: Street Address Work #: City State Zip State Zip TDD/TTY: Yes No Mailing Address City Date of Birth Current Age Male Is there someone to contact in the event of an emergency? Yes Name Female No Relationship to Applicant: Street Address Home #: City State Zip Work #: VanGO services you are applying for? Door to Door Service for seniors and/or disabled Transportation to Dialysis Reduced Fare Card Transportation to Senior Center For Office Use Only ADA Specialize.
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How to fill out the MD VanGo Specialized Services Application online
Completing the MD VanGo Specialized Services Application online is a straightforward process that enables you to request essential transportation services tailored to your needs. This guide provides step-by-step instructions to help you fill out the application accurately and comprehensively.
Follow the steps to successfully complete the MD VanGo Specialized Services Application online.
- Click the ‘Get Form’ button to access the application form and open it for completion.
- Begin with the General Information section. Fill in your full name, home and work phone numbers, street address, and mailing address. Be sure to include your city, state, and zip code. Also, provide your date of birth and current age. Indicate your preferred emergency contact's name, relation to you, and their contact information.
- In the General Information section, specify the VanGO services for which you are applying, such as door-to-door service, transportation to dialysis, or a reduced fare card. Ensure all applicable boxes are checked.
- Proceed to Section 2 on Disability Information. Detail the types of disabilities you have and provide a description for each. Indicate the duration of your disabilities (permanent, temporary, or unknown) and list any mobility aids you use.
- Clearly describe how each disability affects your ability to use public transit, including any other relevant effects. For each specific disability, elaborate on how it restricts your public transit usage.
- In Section 3, list your frequent destinations along with their addresses and how often you travel to these locations. Provide details about your ability to access your curb or driveway without assistance.
- Complete Section 4, the Applicant Certification. Sign and date the form, affirming that the information you provided is correct.
- If applicable, fill out any information required for professional verification to confirm your disability status. This part must be completed by a healthcare professional familiar with your condition.
- Review your completed application for accuracy and completeness. Once satisfied, save your changes, and consider downloading or printing a copy for your records.
- Submit your application as instructed, whether via mail or fax.
Begin the application process online today to ensure your transportation needs are met!
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