Reduced Fare Application
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Phone
*
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
I use the following mobility device:
Wheelchair
Scooter
Cane
Crutches
Other
Please check the appropriate category in which you are applying:
*
Child (free): Ages 0 - 5 years old. (On 6th birthday, fare will be changed to student fare.)
Student/Youth: Ages 6 - 17 years old. (On 18th birthday, fare will be changed to full fare.)
Senior: Age 60 years and older.
Temporarily Disabled: Mobility limitations or self-care limitations.*
Permanently Disabled: Mobility limitations or self-care limitations.
*If you selected Temporarily Disabled above, what is the date of expected end of disability:
-
Month
-
Day
Year
Date
A Certificate of Eligibility will be issued upon receipt of completed application. By signing, you are attesting to the accuracy of this application.
*
Date
*
/
Month
/
Day
Year
Date
Preview PDF
Submit
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