Application For The Maryland Transit Administration'S Reduced Fare Program (Page 3 of 3) in pdf

Application For The Maryland Transit Administration'S Reduced Fare Program Page 3

1. Disability

Provide detailed and specific explanation of applicant’s disability and how it specifically impairs

his/her ability to use MTA’s transit services (Bus, Metro, and Light Rail).

________________________________________________________________________

2. What is the expected duration of the disability?

_____ Temporary: Short-term conditions lasting for at least 90 days but likely to improve within

one year. Please check timing below:

_______ 3 month’s

_______ 6 month’s

_______ 9 month’s

_______ 1 yr

_____ Permanent: Conditions with no expectation of improvement.

Verification and Authorization:

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

correct. I understand that the MTA will rely upon this information in making a determination

as to the eligibility of participation in the program.

______________________________________________

Printed Name of Physician/Healthcare Professional

______________________________________________

Signature of Physician/Healthcare Professional

Office Use Only

______________________________________________

Date

Card Number: _________________________

Exp. Date: _________Category: ___________

Mail to: MTA Certification Office

6 St. Paul Street

Approved By: __________________________

Floor

Issue Date: _________

Baltimore, MD 21202

410-767-3438

Application For The Maryland Transit Administration'S Reduced Fare Program Page 3