APPLICATION FOR MOUNTAIN LINE

DISCOUNT FARE CERTIFICATION

NAME:

ADDRESS:

PHONE NUMBER: AGE:

ATTACH proof of Social Security disability, Medicare, or a letter from your physician or knowledgeable professional.

I have the following disability:

This disability limits my mobility and I am (check one):

( ) Confined to a wheelchair ( ) Crutches

( ) Use a walker, a cane, or braces ( ) Visually impaired

( ) Other (describe)

My disability is (check one): ( ) Temporary ( ) Permanent

UPON APPROVAL, A DISCOUNT FARE CARD WILL BE SENT TO YOU. DISCOUNT FARE CARD MUST BE SHOWN TO THE OPERATOR WITH FARE.

RETURN APPLICATION TO: MOUNTAIN LINE

1221 SHAKESPEARE

MISSOULA, MT 59802