Reduced Fare and Support Person Application

Please complete and submit the Applicant portion of this form.  You will receive an email containing the Professional Certification portion which must be printed and completed by a Health Care Professional.  

Print form

ADDRESS:

Regarding fixed route transit service – bus stops – please select one:

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 specialized transit services discussed with the health care professional that completed part of this application.

The next portion of this form - REQUEST FOR PROFESSIONAL CERTIFICATION - must be filled out by an appropriate health care professional.

If your disability prevents you from using the City Of Belleville regular fixed-route transit service, one of the following health care professionals, as appropriate to your case, must complete the professional certification part of this application form: Licensed physician, Registered occupational therapist, Licensed physical therapist, Certified psychologist/psychiatrist, Licensed optometrist/ophthalmologist/eye physician, Registered Nurse.

Note: Applicants who are the recipient of the Government Sponsored Assistance may substitute a leter from their case worker in lieu of the Physician's statement.

Personal information on this form is collected under the authority of the Municipal Freedom of Information and Privacy Protection Act and will be used to assess the individual’s qualifications for the service and will remain Confidential.