Appendix A to Subpart H of Part 37—Service Request Form

Form for Advance Notice Requests and Provision of Equivalent Service

1. Operator�s name _________________________________

2. Address_________________________________

_________________________________

3. Phone number:_________________________________

4. Passenger�s name:_________________________________

5. Address:_________________________________

_________________________________

6. Phone number:_________________________________

7. Scheduled date(s) and time(s) of trip(s):_________________________________

_________________________________

8. Date and time of request:_________________________________

9. Location(s) of need for accessible bus or equivalent service, as applicable:_________________________________

10. Was accessible bus or equivalent service, as applicable, provided for trip(s)? Yes ____ no ____

11. Was there a basis recognized by U.S. Department of transportation regulations for not providing an accessible bus or equivalent service, as applicable, for the trip(s)? Yes ____ no ____

If yes, explain_________________________________

_________________________________

[66 FR 9054, Feb. 6, 2001]