2. EDTAP Application
   Please fill out this form in its entirety. A person age 60 or above and/or a person on disability may apply for this program. If you are applying by age, you must submit a copy of your picture ID for age verification. If you are applying by disability, you must submit a copy of your disability letter for verification. Any applications sent with out a picture ID/Disability letter WILL NOT be processed until your picture ID/Disability letter is received.
4. Last Name
5. First Name
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Email Address If Applicable
16. Race
    -- Select One --WhiteBlackAsian Pacific IslanderAlaskan / Native American
17. Date of Birth
19. Please Check All That Apply

    1. Ambulatory (Can Walk Without Assistance)
    2. Ambulatory But Need A Lift Van
    3. Attendant Needed
    4. Wheelchair
    5. Wheelchair With Attendant
    6. Cane
    7. Walker
    8. Legally Blind
    9. Elderly/Frail
    10. History Of Seizures
    11. Hearing Impaired
    12. Diabetic
    13. Other (Please Specify Below)
21. Please Specify "Other" Need
23. PLEASE READ CAREFULLY
    A copy of your picture ID or Disability Letter must be submitted or your application will not be processed
25. Please Check The Box That Applies

    1. An electronic copy of my picture ID/Disability letter has been emailed to carts@cravencountync.gov
    2. A copy of my picture ID/Disability letter has been mailed
27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
30. Date
    Date
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field