Mobility Program Application - Fairfield County Transit

Application Details

Application Date (MM/DD/YYYY)

Applicant Information

First Name

Middle Initial

Last Name

Address

Phone Number

City

State

Zip Code

Gender

Date of Birth (MM/DD/YYYY)

Mobility Needs

Mobility Need

Elderly

Disabled

Veteran

Assistance Needed

Service Animal

Personal Care Attendant

Wheelchair

Lift

Door to Door

Emergency Contact Information

First Name

Last Name

Relationship

Phone

Additional Information

Comments or Important Information

Applicant Agreement

I agree that I have provided true and accurate documentation to Fairfield County Transit for the purpose of qualifying for a Mobility Passport which I can use to obtain a discount on rides I schedule with FCT. I agree that if I qualify for a Mobility Passport, I will use it only for myself and will not share it. I also understand that my Mobility Passport may be revoked at any time if its use is abused.

Applicant Signature

Date Signed

Office Use Only

To be completed by Fairfield County Transit staff

Received Date

Processed By

Mailed Date

Return Address: 746 Lawrence Street, Lancaster, Ohio 43130