TriMet Honored Citizen Application (230386)

Under Applicant information (Please print legibly), enter the Name as Last name and First name.

Enter the Mailing address as Street, City, State and Zip.

Enter the Date of birth, the Telephone number and the Email address.

Check I need a replacement ID card if the card was lost, stolen, or damaged.

In the Certification of eligibility section, check only one box.

To qualify under the Health care provider certification type of eligibility, you must complete the health care provider certification section and submit this application to TriMet within 30 days of the date completed by the health care provider.

For Social Security, attach benefit verification to this application.

For Medicare card, to qualify, present Medicare card and government-issued photo ID.

Certified agency requires a TriMet-issued verification stamp on reverse side.

For Senior (65+), 65 years of age or older, you must present a government-issued photo ID.

For Active Military/Veteran, attach VA discharge documentation or present an ID indicating active military or veteran status.

Visitor ID is 30 days maximum. A visitor must show a Transit Agency-issued ID card to qualify. Enter the City and state of agency.

By signing, you agree to release the information you are sending to TriMet for the purpose of making this application for an Honored Citizen ID card. You certify that the information you provide concerning your application is true and correct. You understand that it reserves the right to require proof of disability in addition to this form. You give your consent for it, or a Designated Administrative Agency, to take and retain a copy of your photo. It will not accept a photocopy, fax or email of this form. The application must be completed by hand.

Enter the Signature of applicant and the Date.

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

Under Patient/applicant release, enter the Name of certified and/or licensed health care provider after I authorize, to verify my disability if requested by TriMet.

Enter the Patient/applicant signature and the Date.

The licensed health care provider enters the Applicant's name, Applicant's date of birth, Health care provider's name, Title, State certification or license #, Telephone number, Email address and Address.

To be completed by licensed health care provider*: Physician, Physician Assistant, Licensed Clinical Social Worker, CADC (Certified Alcohol and Drug Counselor), QMHP, Registered Nurse Practitioner.

TriMet-issued agency stamp HERE, with Agency representative's signature, Address and Date.

After I, the health care provider enters their name and certifies that they have examined the patient and that, in the provider's opinion, the patient is disabled due to illness, congenital malfunction or other incapacity that substantially limits one or more major life functions.

If actively enrolled in a drug or alcohol treatment program, check Is actively enrolled in a drug or alcohol treatment program and enter the Duration in months (Maximum of 12).

If the disability is permanent, check Has a permanent disability (5-year Honored Citizen status).

If the disability is temporary (defined as impairment lasting not more than 12 months), check Has a temporary disability and enter the Duration in months.

If permanent or temporary disability, provide a specific description of disability or attach to application on official letterhead.

Check yes or no for: Does the described disability necessitate that the applicant have an attendant to ride TriMet service?

The health care provider certifies that it is correct and that they are legally certified and/or licensed in their state as a healthcare provider, and enters the Signature and Date.

TriMet personnel may contact you for verification.