PERRY COUNTY TRANSIT

Application for Honored Citizen Eligibility

Reduced fare only applies within Perry County

Accessibility (feel free to call if any other accessibilities are needed)

Perry County Transit is offering reduced fares for riders who are veterans and active duty. Funding for these fare discounts are subsidized through the Ohio Department of Transportation, which has established specific eligibility requirements.

Obtaining your ride discount is easy and free of charge. Please follow these simple steps allowing up to 5 days for your eligibility of reduced fare to be applied.

To qualify for reduced fare based on your SERVICE: Complete Sections A & B

Submit this completed application form with proof of service.

Acceptable verification of Service: VIC (Veteran ID Card, CAC Card, VA Benefits Card, DD-214, State Identification card (issued by the Ohio Bureau of Motor Vehicles).

The Administration of Perry County Transit is solely responsible for the approval or rejection of applications for reduced fare eligibility based on program criteria. Appeals may be made to the Perry County Commissioners and the Ohio Department of Transportation. Completed application, and verification of Eligibility and requests for assistance in completing this application should be addressed to Perry County Transit, 499 N State St, New Lexington, Ohio 43764. Phone number (740) 342-2810

Section A

Last name

First Name

M.I.

Date of Birth

Address

City, State & Zip Code

Phone

Height

Weight

Gender

Hair

Eyes

Nationality

I am applying for Perry County Transit reduced fare based on Service (acceptable proof of service must be presented with the application)

Branch of service

Service date

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PERRY COUNTY TRANSIT

Section B

This information will only be used to determine eligibility for the reduced fare program for the Elderly and disabled program.

I state that the above statements are correct and true to the best of my knowledge. I understand that false statements on this application represent a violation of the conditions and terms of the program and will result in the denial of the privilege by Perry County Transit.

Applicant signature (If under 18, parent or guardian's signature)

Date

For Official Use Only

Approved By

Date

Number

THANK YOU FOR CHOOSING THE SERVICES OF PERRY COUNTY TRANSIT

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