Half-Fare Application – Shoreline Metro

Applicant Name *

First

Last

Applicant Address *

Street address, city, state and ZIP

Applicant Phone Number *

Applicant Email

Please check the box(es) that accurately represent you *

Disabled
65 years of age or older
Veteran

Please check all that apply.

Date of Birth *

Physician Name (If Disabled)

First

Last

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. The following professional(s) is most familiar with my disability/health condition and is/are authorized to provide Shoreline Metro with the information required to complete this certification.

Medical Professional/Treating Physician Contact Information (If Disabled)

Please include address, facility, and phone number.

Please describe your disability

If you have a disability, please provide details of the disability or disabilities.

I hereby authorize the above professional to provide the required information to Shoreline Metro. Furthermore, I understand that it may be necessary for me to participate in an in-person evaluation to determine my eligibility for specialized transportation services. I certify that the information here and on the preceding pages is correct. I understand that falsification of information may result in denial of service.

I Agree
I Disagree

To the best of my knowledge the above information is true and factual. I understand that falsification, distortion, or misrepresentation of information may result in denial of the application. Further, an incomplete application may delay in the certification process. *

I Agree
I Disagree