Application For The Maryland Transit Administration'S Reduced Fare Program printable pdf download

Application For The Maryland Transit Administration'S Reduced Fare Program

Application for the Maryland Transit Administration’s

Reduced Fare Program

This information will be used to determine the applicant’s eligibility for the Maryland

Transit Administration’s (MTA) Reduced Fare Program for people with disabilities. The

MTA will assess all information provided and determine eligibility and duration for

participation in the MTA Reduced Fare Program.

To qualify as a disabled individual, the applicant must, by reason of illness, injury,

congenital malfunction, or other disability which is expected to last 90 days or longer, be

unable to utilize mass transit as effectively as others. Conditions which do not qualify

are: pregnancy, obesity, controlled epilepsy, contagious diseases which pose a danger to

other passengers, and less severe mental illnesses. The applicant must fill out Section 1

and have his/her physician or healthcare professional fill out and sign Section 2 of this

application.

SECTION 1: Applicant Information and Release

Mr./Ms. First Name: _____________ Middle Name: _____________ Last Name: __________________

Street Address: ______________________________________________ Apt. ____________________

City: _________________________________ State: ________________ Zip: _____________________

Date of Birth: __________________________ Telephone Number: _____________________________

Current Disabled I.D. Holder: Yes_________ No_________

I hereby authorize my physician or health care professional completing this application to release to

the Maryland Transit Administration (MTA) information about my disability in order to verify my

eligibility for a Reduced Fare I.D. card.

I hereby certify, under the penalties of perjury, that the information given above is true and correct.

Signature of Applicant: _________________________________ Date: ___________________________

Application For The Maryland Transit Administration'S Reduced Fare Program