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Greencard Application

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					                          GREENVILLE TRANSIT SYSTEM
                               Application for Green Card
                                 Elderly / Disabled Fare

  Name
  Address
  City                                       State                  Zip
  Home Phone                                   Alternate Phone
  Date of Birth

  Please check () the appropriate box:
  Yes         No
                   Elderly (65 years of age or older)
                   Disabled
                   Do you use any mobility aids
                   If yes, check () all that apply
                         Manual Wheelchair
                         Electric Wheelchair
                         Powered Scooter
                         Cane or Walker
                         Crutches
                         Leader Dog
                         Others (please list):
                   Do you require a Personal Care Attendant when traveling?
    Yes     No
                                         Permanent
                   Your Disability is:
                                         Temporary


   Signed                                                           Date
              Return completed form with Proof of Age or Disability to:
                              Public Transportation Director
                                Greenville Transit System
                                 1425 KitchenAid Way
                                Greenville, Ohio 45331
                                    FAX 937-548-1704


Date Card Issued                                      Card Number

				
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posted:7/25/2009
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