City Of Tucson Transit Reduced Fare Program - Disabled Application Form (Page 3 of 3) in pdf

Disabled Application

Special Designations Only for Persons with ADA Paratransit Eligibility Card:

Individuals who have been approved for either a Personal Care Attendant (PCA) or Segway and have this

designation on their ADA Paratransit Eligibility Card can use this as proof to obtain the Sun Tran disability

ID with the same designation. Please indicate which you are applying for:

 Personal Care Attendant

 Segway

E. Certification from physician (to be completed by physician or other licensed health care provider)

Important note to physicians & health care providers: The criterion for eligibility is the functional ability of

your patient to use regularly scheduled transit service. If the applicant is able to use such service, but

experiences difficulty in doing so due to his/her medical condition, he/she is eligible. Certification forms

will be confidential records.

Physician/Licensed Health Care Provider:

Name of physician/licensed health care provider: _____________________________ Phone: ______________

Office Address: ______________________________________________ City: ___________________________

State: __________

Zip: _________ State Professional License No.: _________________________________

Please complete the following section regarding the applicant’s disability. Check all that apply.

 Non-ambulatory

 Semi-ambulatory

 Amputation

 Sight impairment

 Cardiac or Pulmonary condition

 Mental impairment/illness

 Hearing impairment

 Epilepsy

 Brain, spinal, peripheral nerve injury or arthritic condition

 Chronic progressive debilitating condition

 Other (please explain):_____________________________________________________________________

Signature of physician/licensed health care provider: __________________________ Physician ID#__________

3. Valid Photo ID

One valid photo ID is also required. Check which form of ID you are providing.

 Driver’s license

 State ID card

 Passport

 Government-issued ID

 Tribal ID

4. Statement of Truth

I agree that the statements made about my disability and all other information that relates to my eligibility for

benefits is true and correct to the best of my knowledge, and that I have not withheld any information. Permis-

sion is hereby granted to Authorized Agent to contact any sources necessary to establish the accuracy of

information given by me or other information that pertains to the verification of my eligibility to receive

reduced fares based on my disability. I understand that my application will be denied if the information

provided is found to be untrue. The signature below certifies that all information relative to eligibility is correct.

In accordance with the Tucson City Code (Sec. 2-22.1) any person providing false information or refusal to

provide information is punishable by a $500 fine and may be deemed ineligible for the economy fare for up

to five (5) years.

Applicant’s Signature___________________________________________ Date ____ /____ /_______

(2 of 2)

rev 3/1/13

City Of Tucson Transit Reduced Fare Program - Disabled Application Form Page 3

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