Disability Identification Card Application Form
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2DISABILITY IDENTIFICATION CARD APPLICATION
Persons with disabilities are entitled to a discounted fare on Gold Coast Transit (GCT) fixed-route bus
service. The GCT Disability ID Card, a Medicare card or ADA Paratransit ID card must be shown to the driver
each time you board the bus to qualify for the reduced fare. If proper ID is not shown, the reduced disabled
fare does not apply.
Completed applications MUST BE RETURNED IN PERSON by the applicant to the GCT Customer Service
Center, Oxnard Transit Center, 201 E. Fourth Street, Oxnard, CA. Incomplete applications will not be
accepted. A photo will be taken for the identification card at that time.
SECTION 1: To be completed by the applicant or by someone on the applicant’s behalf.
Please print legibly or type.
Applicant’s Name
Address (include Apt. #)
City
State
Zip Code
Phone Number
Birthdate
Emergency contact person
Relationship
Phone Number
I hereby authorize the person listed in Section 2 of this application to release to Gold Coast Transit medical, or other
pertinent information, about my disability. The information released will be used solely to determine my eligibility for
this Disability Identification Card.
Applicant’s Signature
Date
SECTION 2: To be completed by a physician or licensed medical professional, licensed optometrist (for
visual impairments), or counselor/social worker (representing a recognized organization
for persons with disabilities). Please print legibly or type.
I hereby certify that the applicant qualifies under Criteria Number(s) __________ (list all that apply), as listed on
the other side of this application, for the GCT Disability Identification Card.
The disability is: (check one) ______ Permanent
_________ Temporary, and the expected duration is: ________
I am legally licensed as a ______________________________ in the State of California and hereby declare that the
information provided is true and correct.
Name
Signature
License #
Date
Organization Name
Phone Number
Business Address
City
State
Zip Code
Return this form to the applicant.
79
805-487-4222 |
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