Required fields are marked with asterisks (*)

Reduced Fare Application

After completing and submitting this form you will receive an email containing the Professional Certification portion which must be completed by a Health Care Professional.

I confirm that I am a City of Belleville resident (Ward 1)

Yes

Applicant Information

First name

Last Name

House or 911 number:

Apt. or unit #:

City

Postal Code

Primary Phone Number

Secondary Phone Number

E-Mail Address

Emergency Contact

Name:

Relationship:

Phone Number:

Mobility Requirements

Transportation needs (select all that apply):

Require a mobility aid (e.g., wheelchair, walker, scooter, etc.)

Vision-related limitations affecting independent travel

Cognitive, neurological, or medical condition affecting safe independent travel

Other accessibility-related conditions affecting transit use (please specify):

I need to travel with an attendant

Yes

APPLICANT DECLARATION

I hereby certify that to the best of my knowledge, the information given above is correct. I authorize the release of medical information to the City Of Belleville. I consent to the contents of my application and eligibility for reduced fare transit services discussed with the health care professional that completed part of this application.

Signature of Applicant or Designate

Clear

Date

Your application must be certified by a health care professional before your Reduced Fare Pass can be issued.

Upon submission of this form, you will receive an email containing a Professional Certification form, which must be completed by your health care professional.

Acceptable health care professionals include:

Licensed physician
Registered occupational therapist
Licensed physical therapist
Certified psychologist/psychiatrist
Licensed optometrist/ophthalmologist/eye physician
Registered Nurse

Applicants who are recipient of Government Sponsored Assistance may substitute a letter from their case worker in lieu of the professional certification form.

I understand that my application is not complete until I submit the Professional Certification forms required.

Yes