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Attachment A <br /> <br />MAIL TO: P~easanton Paratransit Service Phone No. 925-931-5376 <br /> 5353 Sunol Blvd. Fax No. 925-485-3685 <br /> Pleasanton, CA 94566 Hours 9:00 AM to 3:00 PM <br /> <br />Last Name First Name MI <br />Mr. Ms. Mrs.__ Dr.__ Birth Date / / <br />Address Phone No. <br /> Emergency No. <br />City Message No. <br />State Zip <br /> <br />Check ALL that apply to you: <br /> <br />__ Wheelchair __ Need to use lift __ Need an escort when traveling <br /> <br />In case of emergency, we should contact: Phone No.(s) <br /> <br />Name <br /> <br /> Describe any physical or mental condition, which prevent your use of public transit: <br /> <br /> I affirm under penalty of perjury that the statements on this form are true to the best of my knowledge and belief. <br /> <br /> Client or Guardian Signature Date <br /> <br /> __ Ambulatory Stroke __ A.D.A. <br /> ID No. Zone <br /> __ Wheetchair Alzheimers __. Other <br /> THE CITY OF <br /> <br /> __ WaJker __ Dialysis <br /> jDLEAS NTON, __ E,0er,, __ Sight Disability <br /> <br /> <br />