Mbta Transportation Access Pass Form – Fill Out and Use This PDF

COMMONWEALTH OF MASSACHUSETTS

REDUCED FARE PROGRAM Transportation Access Pass/TAP CharlieCard Application

PART A: To Be Completed By Applicant (Please print)

Applicant Information:  First time applicant  Renewal

Last Name___________________ First Name _______________ MI____

Address _____________________________________Apt. No.________

City ______________________________ State ________ Zip_________

Phone ____________________________ DOB _____/_____/__________

E-Mail ______________________________________________________

Emergency Contact Information: Name __________________________

Relationship __________________ Phone _________________________

Disability Information Release Authorization:

I authorize the health care professional completing this application to release information about my disability to the Massachusetts Bay Transportation Authority (MBTA).

_______________________________	______________
Applicant Original Signature	Date

Application Submittal: Please return the completed application to the address below. No photocopies or faxes accepted. If approved, when picking up your card you must present a current photo ID (MA license, State ID, Passport).

You will receive an Application Status Letter in 4 – 6 weeks.

MBTA CharlieCard Store, Downtown Crossing Station

Chauncy Underground Concourse, 7 Chauncy St., Boston, MA 02111

617-222-3200, 617-222-5854/TTY

PART C: Health Care Professional Certification

PART C must be completed by a licensed or certified health care professional, and must be received by the MBTA within 60 days of the health care professional’s signature. Please P-R-I-N-T.

Name of Health Care Professional ________________________________________________

Licensure Title ______________________________Specialty__________________________

License Number _______________________ State Issued ____________________________

Business Address ____________________________________________________________

City _________________________State _______ Zip _________Phone ___________________

IMPORTANT PROGRAM NOTE: The MBTA issues the TAP CharlieCard based on the level of difficulty applicants experience, and the extra planning and effort that may be required, to use public buses/trains/subway due to a physical, psychiatric, intellectual or sensory disability. The TAP CharlieCard is issued to applicants with disabilities who find it moderately/severely difficult to wait for a bus, hear announcements, read visual signs, understand and/or follow directions, board the correct train, maintain stamina, function well in crowds, walk certain distances to transfer between transit modes, etc. The TAP CharlieCard IS NOT ISSUED based on applicant's income level.

1. What is the applicant's disability?

Use GUIDELINE NUMBER(S) from back page_________________________________

Specific Diagnosis __________________________________________

______________________________________________________

2.Does disability cause the applicant difficulty, as described in "Important Program Note" section above, when traveling on the MBTA?

 No  Yes (Please specify) ___________________________________

________________________________________________________________________

3.Expected duration of disability: Please select only one of the two options below.

_________Temporary: Conditions with potential for improvement within 1 year

_________Permanent: Conditions with no expectation of improvement

4.I certify that the information I have provided above about this MBTA TAP CharlieCard applicant is correct to the best of my knowledge:

_____________________________________ ___________________

Original Signature of Health Care Professional

Date