Trimet Honored Citizen – Fill Out and Use This PDF

Trimet Honored Citizen is a discounted ticket program for seniors, people with disabilities and anyone else who qualifies.

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Trimet Honored Citizen PDF Details

The Trimet Honored Citizen Form is a document that allows for citizens of the Portland metropolitan area to receive free or discounted transportation fares from TriMet. The form is available to any resident who is 65 years or older, 16 years or younger, or has a disabilities. In order to qualify for the discounts, riders must present their Honored Citizen Form along with a valid ID at the time of purchase. For more information on how to obtain and use the Trimet Honored Citizen Form, please visit TriMet's website.

The following are some specifics about trimet honored citizen. It's advised that you read through this material before you start fiddling with the PDF.

Question	Answer
Form Name	Trimet Honored Citizen
Form Length	2 pages
Fillable?	Yes
Fillable fields	50
Avg. time to fill out	10 min 30 sec
Other names	trimet honored citizen application, trimet honored citizen card, honored citizen trimet application, trimet honored application fill

12

Form Preview Example

Honored Citizen Application

TriMet Ticket Ofice: 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 Identiication 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 irst 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. $3 fee required.

I need to renew my expired card. $3 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
	certiﬁcation	by the health care provider.
		by the health care provider.

	 Social Security	Attach beneit veriication to this application.

	 Certiﬁed agency	Requires TriMet issued veriication 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, fax or email of this form.

Signature of applicant _________________________________________________ Date ______________________________

140613 • 9/14

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: _____________________________________

To be completed by

licensed health care provider*(see below)

Applicant’s name: _________________________________________

Applicant’s date of birth: ____________________________________

Health care provider’s name: _________________________________

Title: ____________________________________________________

State certiication or license #: _______________________________

Telephone number: ________________________________________

Email address: ____________________________________________

Address: _________________________________________________

_________________________________________________

TriMet issued Agency stamp

HERE

_____________________________________________

Agency representative’s signature

_____________________________________________

Address

_____________________________________________

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 (deined as impairment lasting not more than 12 months). Duration is _______ months.

SPECIFIC description of disability (Please print LEGIBLY and provide suficient detail) or attach description on oficial 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 certiied and/or licensed in my state as a Healthcare Provider.

Signature _______________________________________________________ Date __________________________________

Customer Service staff may contact you for veriication.

Completed application and health care provider certiication may be mailed to the TriMet Ticket Ofice, 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."

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honored citizen empty spaces to fill out

Within the part Social, Security Cert, i, ed, agency Senior, Disabled, veteran Visitor, ID City, and, state, of, agency Medicare, card and Signature, of, applicant, Date note the information which the application asks you to do.

Finishing honored citizen part 2

Provide the relevant particulars in the Patient, applicant, release Patient, applicant, signature, Date Applicants, name Applicants, dateofbirth Healthcare, providers, name Title, State, cert, ii, cation, or, license Telephone, number Email, address Address, Tri, Met, issued, Agency, stamp HERE, Agency, representatives, signature and Address area.

Filling out honored citizen stage 3

As part of section Address, Address, and Date, define the rights and responsibilities.

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