DATE OF CALL _________________________________
TIME OF CALL _________________________________
NAME OF CAR SERVICE __________________________
STREET ADDRESS _______________________________
BOROUGH/ZIP CODE _____________________________
TELEPHONE ____________________________________
PERSON SPOKEN TO _____________________________


WAS A WHEELCHAIR ACCESSIBLE VEHICLE AVAILABLE?
[  ] YES    [  ] NO

IF YES, DID IT ARRIVE WITHIN 15-30 MINUTES OF REQUESTED TIME?
[  ] YES    [  ] NO

IF NO, WHAT REASON WAS GIVEN, IF ANY?
_____________________________________________
_____________________________________________

YOUR NAME ____________________________________
YOUR ADDRESS _________________________________
TELEPHONE ____________________________________

SIGNATURE (REQUIRED) ___________________________________

MAIL FORM TO:

DISABLED IN ACTION
P.O. BOX 30954
NEW YORK, NY 10011

COMPLETE ONE FORM FOR EACH INCIDENT, EVEN IF IT IS WITH THE SAME COMPANY.

IF YOU NEED ASSISTANCE COMPLETING THE FORM, CALL 917-865-3339.

THIS FORM CAN ALSO BE USED IF YOU WERE DENIED ACCESS BECAUSE OF YOUR SERVICE ANIMAL.
[  ] CHECK HERE IF THIS IS THE SITUATION.