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2. Reduced Fare Application

   The information obtained in this aplication will only be used for the provision of Central Transportation specialized transportation services.

4. First Name*
5. Middle Initial
6. Last Name*
8. Address*
9. City*
11. State*
12. Zip Code*
14. E-mail Address
16. Date of Birth (mm/dd/yyyy)*
17. Phone Number*

19. I hereby authorize for release of my health information to complete this application. I understand the information provided in this application is not confidential and is open to Department of Transportation and Federal Transit Administration authorized officials for compliance reviews.

21. Signature*

    Enter your name here.

22. Date*

24. Individuals with disabilities can be certified for the reduced fare program if they have one or more of the following:

26. Check all that apply:

    1. Receiving Medicare/Supplemental Security Income benefits
    2. Ambulatory disability
    3. Hearing impairment
    4. Mental impairment
    5. Legally blind
28. State the nature of your disability.*
30. The limitation is (check one): *

    1. Permanent
    2. Temporary
32. Professional Verification
    In order for your application to be evaluated, it may be necessary to contact a physician or other professional to confirm the information you have provided. Please complete the following information and authorization form.
34. The following professional is most familiar with my health condition and is authorized to provide Central Transportation with the information required to complete this certification.
    Registered Nurse, Case Manager, Rehabilitation Professional, Physical Therapist, Occupational Therapist, Mental Health Professional.
36. Physician/Certifier's Name*
38. Physician/Certifier's Address*
39. City*
41. State*
42. Zip Code*
43. Phone*
45. If determined eligible for reduced fare transportation, you will receive a reduced fare card. The card can only be used by the person to whom it was issued.
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field