Geauga Transit Reduce Fare Application

Application for Elderly & Disabled (E&D) Reduced Fare
Name*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Date of Birth*

MonthDayYear
Date
I use the following mobility device. Check all that apply.

WheelchairScooterCaneCrutchesOther
Please check what qualifies the applicant for a reduced fare. In order to qualify for the E&D fare, the applicant must be at least 65 years old or have a disability that limits their mobility or self-care. We must have documentation supporting applicant's age or disability.*

Elderly: Must be at least 65 years old. Please upload a photo of one of the following documentations: Driver's license, birth certificate, or state issued ID card.Disabled: Must have mobility limitations or self-care limitations. Please upload a photo of one of the following documentations: SSI award letter, SS Disability award letter or have a licensed physician or health care professional complete the following Statement of Disability. (Valid for two years or duration of temporary disability.)
Upload documentation to show proof of eligibility of elderly or disabled from lists above. If you do not have documentation, please have a healthcare professional complete Statement of Disability below.

Cancelof
STATEMENT OF DISABILITY

(meets ADA criteria for Mobility or Self-Care Limitations)
Physician’s Name
Title
Physician’s Phone Number
Date

MonthDayYear
Date
Physician's Signature

Clear
Is the above client’s disability temporary

YesNo
If yes, expected length of temporary disability

MonthDayYear
Date
If you prefer to submit a printed application, you can downloaded an application at www.geaugatransit.com and mail it with a copy of supporting documentation to: Geauga Transit, 12555 Merritt Rd. Chardon, OH 44024

Printed applications can by requested by calling 440-754-5555 or TDD: 1-800-750-0750 or emailing info@geaugatransit.com.
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Application for Elderly & Disabled (E&D) Reduced Fare

STATEMENT OF DISABILITY