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9 <br /> Application for Regional Reduced Fare Permit for Senior and Disabled Persons <br /> II? This application is available in accessible format. <br /> Note: Applicants must be at least 6 years old to be eligible for a For Office Use Only <br /> Regional Reduced Fare Permit. ID# <br /> Please Print PCA <br /> ['Temporary <br /> c__)I Name <br /> First Middle Last ❑Permanent <br /> Date <br /> Address <br /> City State ZIP <br /> Date of Birth Phone No. <br /> Please read the applicant section of the Medical Eligibility Criteria and Conditions brochure before completing this application. <br /> I am applying for a Regional Reduced Fare Permit on the following basis.Please check only one. <br /> Permanent Permit: <br /> I am 65 years of age or older. <br /> nI am providing proof of current eligibility by the Veterans Health Administration as having a disability of at least 40%. <br /> Temporary Permit: <br /> I am providing proof of eligibility and am receiving Social Security Disability Benefits or Supplemental Security <br /> EiIncome Benefits due to disability.(Applicant must show current award letter.) <br /> I am presenting a valid Medicare card issued by the Social Security Administration. <br /> [Ti I am currently participating in a vocational career program with the Washington State Individual Educational <br /> 1-1 Program (IEP). <br /> I am providing a Washington Department of Licensing-issued disabled parking identification in conjunction with <br /> ® a government-issued photo identification. <br /> Permanent or Temporary Permit(case-by-case): <br /> I am providing a valid Regional ADA paratransit card <br /> Elor other supporting materials issued by(Agency) <br /> ADA paratransit card/supporting materials expire(s)on <br /> I have an obvious physical impairment(s)meeting one or more of the medical criteria listed in the Medical <br /> Eligibility Criteria and Conditions brochure. <br /> I am medically disabled as certified by a Physician (M.D.),Psychiatrist,Psychologist(Ph.D.),Physician's Assistant(RA.), <br /> Advanced Registered Nurse Practitioner(A.R.N.P.),Audiologist certified by the American Speech—Language— <br /> Hearing Association,Osteopathic Physician (D.O.)licensed in the State of Washington.See Health Care Provider's <br /> Certification form on the back side of this application.This agency reserves the right to contact your Health Care <br /> Provider for verification. <br /> Applicants Signature Date <br /> 107 <br /> September 2017 <br />