Required fields are marked with asterisks (*)

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.

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First name

Last Name

E-Mail Address

Primary Phone Number

Secondary Phone Number

TTY number:

ADDRESS:

Address number:

Street:

Apt./Suite

City

Postal Code

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

I can usually get to and from a regular transit stop without assistance

This statement applies to me

I can get to and from a regular transit stop Only If: (check all that apply and fill in the blanks as requried)

I have an attendant with me

I need to travel less than an average city block

I receive travel training

The path is free of ice and snow

Other

I can never get to and from a regular transit stop

This statement applies to me

I require a support person for assistance during transit trips

This statement applies to me

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.

Signature of Applicant or Designate

Clear

Date

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.