Electronic Reduced Fare Application -Greater Portland Transit, ME

Section 1: To be completed by Applicant

Name

First Last

Address

Street Address Apt/Unit # City State / Province / Region ZIP / Postal Code

Phone (Include area code)

Date of Birth(Required)

Preferred method of notification

Mail

Phone

Reduced Fare Category(Required)

Senior

Medicare

SSI, SSDI, VA

Veteran

Youth

Disability (with completed Section 2)

Select the reduced fare category for which you are applying.

DiriGo Pass type

DiriGo Pass smartcard

Umo mobile app

Would you like your photo on your smartcard?

Yes (will attach a photo to this form)

This can help return lost/stolen cards and prevent misuse. If a photo is requested, please upload a passport-style photo at the bottom of this form.

Signature

I certify that the information on this application is correct. I give the agency or medical professional permission to release information regarding my disability. I understand that if this application is approved, I will be eligible to receive the reduced fare rate (50% of the regular fare) for the DiriGo Pass Fare System. I will not loan or give use of my card or mobile app to anyone. If paying with cash, I will present my ID card to the bus operator as requested when paying my fare.

Date

How would you like to receive your smartcard?

Mail it to me at the above address

I will pick it up at 21 Elm Street, Portland Maine

Supporting documents(Required)

Drop files here or

Accepted file types: jpg, pdf, png, gif, jpeg, , Max. file size: 25 MB, Max. files: 5.

Use this field to upload required documentation, such as ID’s, physician’s note, and benefit cards required for verification of reduced fare eligibility.

Hidden

To be completed by office staff

Hidden

Date

Hidden

Fare media choice

Smartcard

Umo App

Hidden

Photo?

Yes

Hidden

Expiration Date

Hidden

Type of Documentation

e.g. ID, RWB card, benefit letter, medical

Hidden

Photocopy of supporting documentation made:

Hidden

Username

Hidden

State ID, type, number

Hidden

Notes

Electronic Reduced Fare Application

Qualification Categories for Reduced Fare

Reduced Fare Application

Section 1: To be completed by Applicant

To be completed by office staff