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Reduced Fare Application

  1. Reduced Fare Application

    The information obtained in this application will only be used for the provision of Central Transportation specialized transportation services.

  2. I hereby authorize for release of my health information to complete this application. I understand the information provided in this application is not confidential and is open to Department of Transportation and Federal Transit Administration authorized officials for compliance reviews.

  3. Enter your name here.

  4. Individuals with disabilities can be certified for the reduced fare program if they have one or more of the following:

  5. Check all that apply:
  6. The limitation is (check one): *
  7. Professional Verification
    In order for your application to be evaluated, it may be necessary to contact a physician or other professional to confirm the information you have provided. Please complete the following information and authorization form.
  8. The following professional is most familiar with my health condition and is authorized to provide Central Transportation with the information required to complete this certification.
    Registered Nurse, Case Manager, Rehabilitation Professional, Physical Therapist, Occupational Therapist, Mental Health Professional.
  9. If determined eligible for reduced fare transportation, you will receive a reduced fare card. The card can only be used by the person to whom it was issued.
  10. Leave This Blank:

  11. This field is not part of the form submission.