There are 2 parts to this application:


  • Requests information about the applicant, including any special needs or limitations which the individual may have.
  • Must be filled out completely, either by the applicant or by someone who is assisting the applicant.
  • Contains a HIPAA Authorization on page 12. This must be completed by the applicant or by the applicant’s Power of Attorney.


  • Must be filled out completely, and by only one individual.
  • Please read page 13 to determine who may complete Part 2.
  • The individual who completes Part 2 must also sign where indicated on page 19.


NOTE:  For your convenience, following Part 2 there is a checklist which you can use to be sure that you have filled out this application completely.

Following the checklist, there is information regarding the re-certification process, plus the appeals process in the event that you do not agree with the determination of your eligibility status.


Part 1 - Application Information

Purpose of this Application *
Please select

Part 1 - Home Address

Home Address State *

Part 1 - Mailing Address

Please provide if your Home Address is NOT your Mailing Address

Mailing Address State

Part 1 - Contact Information

Preferred Contact
How do you communicate? *
Primary Language *

Part 1 - Contact Information

Alternate Contact Person [if you wish, you may give us the name and telephone number of someone who may act on your behalf]:


Please indicate any situation where you may use the Centro Fixed Route or Call-A-Bus service:

(Part 1 - continued)

I can travel, but I need the help of a guide or aide: [If yes, you must provide your own aide, guide, or escort.] *
Please check any statement that describes your abilities *
I can travel on my own (walking, using my manual wheelchair, using my cane or walker) *
My power wheelchair or scooter gives me the mobility to travel long distances
I can get to the bus stop near my home *

(Part 1 continued)

Please check a response for each of the following statements:

I use Centro Fixed Route Buses *
I want to learn to use Centro Fixed Route Buses *
I can get to the Centro Fixed Route Bus Stop *
I can ask for and follow directions *
I can wait outside at the bus stop without a bench or something to lean on *
I can wait outside in cold weather for 10 minutes *

(Part 1 continued)

Please check a response for each of the following statements:

I can wait outside in hot weather for 10 minutes *
I can get on and off a bus without assistance *
I can put my money or pass in the fare box *
I can recognize where to get off the bus *
I can transfer from one bus to another *
I can get from the bus to places I want to go *

(Part 1 continued)

Please check all that apply that would prevent you from getting to and from your origin and destination. For each box checked, please provide a detailed explanation of how travel is affected.

(Part 1 - continued)

I use the following aids or devices when I travel: (Call-A-Bus does not provide mobility aids for passengers). Check all that apply. *
Did Someone other than the applicant complete this form? *
Address State *
How did you assist in completing this form: *

By filling out this PART 1 online you:

  • Agree that you have read and understand the directions on how to complete PART 1 of the application.
  • Agree that you have read and understand the directions on who can complete PART 2 of the application.
  • Understand that you must still print PART 2 of the application and bring it to your Healthcare Professional to complete (along with your completed PART 1 for Healthcare Professional to review).
  • Understand that you must mail or bring the completed ORIGINAL PART 2 to the Centro Call-A-Bus office.
  • Understand you or your power of attorney must sign and return the HIPPA authorization with your completed application.
  • Understand that you will receive an email containing both your completed PART 1 and a link for PART 2.