Date issued: FOR OFFICE USE ONLY APPLICATION FOR DISABLED IDENTIFICATION CARD Issued By: ID #: Exp. Date: 3 Doctor/MD 4 Social Service Agency PART I - APPLICANT ( Please Print or Type) new lost replaced Mr. Mrs. Ms. Last Name First Name Middle Initial Address: Apt. City/State: Zip Code: Phone: Birthdate: / / ID#: MO DAY YR *** MUST PRESENT A CURRENT, VALID TEXAS PHOTO ID *** PART II I_____________________________________ , hereby agree to the release and authorize the health care professional completing this application to release to Sun Metro Transit information about my disability in order to verify my eligibility for reduced-fare transportation. The information provided will allow Sun Metro to make an appropriate evaluation of this request and its application for reduced-fare transportation. PART III Must be completed by Doctor/MD only & accompanied by Doctor’s certification – no exceptions PART III PERMANENT (As Defined by Criteria Checked on Reverse Side) This information certified true and correct. Name Agency Address Signature Title Phone City Date PART IV Must be completed by Doctor/MD, Social Service Agency or Mobility Instructor PART IV TEMPORARY (As Defined by Criteria Checked on Reverse Side) This applicant has a temporary disability which can be expected to last months. This information certified true and correct. (no more than 12 months) Name Title Agency Social Service Worker Cert # Phone Address City Signature SM(A) 20 (7/11) Date
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