Trimet Honored Citizen Application Form – Fill Out and Use This PDF

Honored Citizen Application

TriMet Ticket Office: 701 SW 6th Avenue, Portland, OR 97204

503-962-2455 • accessible@trimet.org

Hours: Monday–Friday 8:30 a.m.-5:30 p.m.

To use an Honored Citizen fare, a person must present one of the following when asked by TriMet personnel: Photo ID showing proof of age 65 or older, a red, white and blue Medicare card with photo ID, or a TriMet Honored Citizen Photo Identification Card—issued after completing this form. Application must be submitted in person along with government issued photo ID. Requires photo taken by TriMet.

Applicant information (PLEASE PRINT LEGIBLY)

Name:	_____________________________________ , _______________________________________________
	Last name	First name
Mailing address:	_____________________________________	__________________________	_______	__________
	Street	City	State	Zip
Date of birth:	_____________________________________
Telephone number: ( _____ ) ______________________________		Email address: __________________________________

I am applying for a TriMet Honored Citizen ID Card.

This is my first ID card. Application must be submitted in person, requires photo taken by TriMet.

I need a replacement ID card; my card was lost, stolen, or damaged. $5 fee required.

I need to renew my expired card. $5 fee is required if renewing a card that was issued for up to 12 months. Application must be submitted in person, requires photo taken by TriMet.

I am applying for a TriMet Honored Citizen Downtown Pass

$10 fee required. For details, the program description is available at trimet.org/hc OR THE TRIMET TICKET OFfiCE.

Note: Fee payable by cash, check, money order or credit/debit card.

Certification of eligibility section (Check only one box below)

	 Health care provider	To qualify under this type of eligibility you must have the health care provider certification section
	certification	on the reverse side completed. Please return this application within 30 days of the date completed
		by the health care provider.
	 Social Security	Attach benefit verification to this application.
	 Certified agency	Requires TriMet issued verification stamp on reverse side.
	 Senior (65+)	65 years of age or older. Must present government issued photo ID.
	 Disabled veteran	Attach VA documentation to this application.
	 Visitor ID	30 days maximum. Visitor must show Transit Agency issued ID card to qualify.
		City and state of agency ___________________________________________________________
	 Medicare card	To qualify present Medicare card and government issued photo ID.

I agree to release the information I am sending to TriMet for the purpose of making this application for an Honored Citizen ID Card. I certify that the information I provide concerning my application is true and correct. I understand that TriMet reserves the right to require proof of disability in addition to this form. If applying for the Honored Citizen Downtown Pass/ID Card, I agree to abide by the terms of the program description, and photo ID card. I give my consent for TriMet, or a TriMet Designated Administrative Agency**, to take and retain a copy of my photo. TriMet will not accept a photocopy or fax of this form.

Signature of applicant _________________________________________________ Date ______________________________

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Health care provider certification section: This form is used for Individuals with permanent or temporary disabilities. This also includes individuals who may need an attendant to ride TriMet service.

Patient/applicant release:

I authorize: _________________________________________________	to verify my disability if requested to do so by TriMet.
(Name of certified and/or licensed health care provider*)
Patient/applicant signature: ___________________________________	Date: _____________________________________

I, _________________________________________________ hereby certify that I have examined the patient listed above and

(Name of certified and/or licensed health care provider*)

it is my opinion that he/she is disabled due to illness, congenital malfunction or other incapacity that substantially limits one or more major life functions.

Disability is:

Permanent

Temporary (defined as impairment lasting not more than 12 months). Duration is _______ months.

SPECIFIC description of disability (Please print LEGIBLY and provide sufficient detail) or attach description on official letterhead form:

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

 yes  no Does the described disability necessitate that the applicant have an attendant to ride TriMet service?

I certify that the above is correct and that I am legally certified and/or licensed in my state as a Healthcare Provider.

Signature _______________________________________________________ Date __________________________________

Customer Service staff may contact you for verification.

Completed application and health care provider certification may be mailed to the TriMet Ticket Office, 701 SW 6th Avenue, Portland, OR 97204

503-962-2455 • accessible@trimet.org • trimet.org/hc

*Physician, Physician Assistant, Licensed Clinical Social Worker, CADC (Certified Alcohol and Drug Counselor) , QMHP, Registered Nurse Practitioner, or Counselor certified by the Addiction Counselor Certification Board of Oregon (ACCBO) .

**For the purpose of simplifying administration of the Honored Citizen Program, social service agencies or other organizations that are interested in processing TriMet Honored Citizen Card Applications for their clients may be selected, at TriMet's discretion, to operate as a "Designated

Administrative Agency."