HomeMy WebLinkAboutApplication_Form_for_Reduced_Fare_Program
Thank you for your interest in obtaining a GO Transit system reduced fare ID card. This program offers
discounted fixed-route bus fare to qualified individuals when utilizing the WisGo fare collection system (fare
ID card). There are four categories used to determine eligibility:
1) Individual is age 60 or over (with proof of age).
2) Individual is currently covered under Medicare (Medicaid is not applicable).
3) Individual currently has a valid GO Transit issued ADA Paratransit Card.
4) Individual has a qualifying physical or mental impairment.
All applicants must complete ONE of the following:
1) If you are age 60 or older:
a. Complete and sign page 1 of the application.
b. Provide photo ID with proof of age.
2) If you are covered under Medicare:
a. Complete and sign page 1 of the application.
b. Bring your current Medicare ID Card
(Forward Card not accepted).
c. Provide photo ID.
3) If you have a valid GO Transit issued ADA Paratransit Card:
a. Complete and sign page 1 of the application.
b. Bring your current ADA Paratransit Card.
c. Provide Photo ID.
4) If you have a qualifying disability and are under age 60:
a. Complete and sign page 1 of the application.
b. Have a licensed professional (doctor, nurse, social worker) complete page 2 of the application.
c. Provide photo ID.
Bring your completed application and photo ID (and Medicare ID Card, current ADA Paratransit Card or page
2 of the application signed by a licensed professional, if applicable) to the GO Transit Office at 926 Dempsey
Trail during office hours (Monday – Friday from 8AM-4:30PM, Closed for lunch 12PM-1PM).
Please note: Your application cannot be processed if:
• you fail to provide photo identification.
• your application is incomplete or inaccurate.
• you are applying due to a qualifying disability and do not provide a completed medical
verification (page 2 of the application signed by a licensed professional).
There is no cost to apply for the Reduced Fare Program. Once issued, if a participant’s card is lost or stolen, a
replacement card will be issued at a cost of $5.00. GO Transit Reduced Fare ID Cards are to be used
exclusively by the individual named on the card. Allowing others to use the card is prohibited and will result
in immediate loss of program eligibility.
Please call 920.232.5340 if you have questions or concerns regarding the GO Transit Reduced Fare Program.
Reduced Fare Program Application Instructions
Page 1
LAST NAME: ________________________________ FIRST NAME: ____________________________
STREET ADDRESS: _____________________________________ Oshkosh, WI ZIP CODE: __________
DATE OF BIRTH: ______________ PHONE NUMBER: _________________________________
EMAIL: _____________________________________________________
How would you like to pay your fare? Please choose one of the options below:
☐ UMO app on phone (please provide email above and have the app already downloaded before applying)
☐ WisGo reloadable card
Check the appropriate box and sign below:
☐ I am 60 or older. (Provide photo ID with proof of age.)
☐ I am currently covered under Medicare. (Provide photo ID and Medicare Card.)
☐ *I have a valid GO Transit issued ADA Paratransit Card. (Provide photo ID and ADA Paratransit Card.)
☐ *I have a physical or mental impairment, which meets the FTA definition (609.3) of a person
with a disability, as listed below. (Licensed Professional must complete page 2 of application.)
“Handicapped persons means those individuals who, by reason of illness, injury, congenital malfunction, or
other permanent or temporary incapacity or disability, including those who are non-ambulatory wheelchair-
bound and those with semi-ambulatory capabilities, are unable without special facilities or special planning or
design to utilize mass transportation facilities and services as effectively as persons who are not so affected.”
“Disability means, with respect to an individual, a physical or mental impairment that substantially limits one
or more life activities of such individual; a record of such an impairment; or being regarded as having such an
impairment.” Major life activities include, but are not limited to caring for one’s self, performing manual tasks,
walking, seeing, hearing, breathing, learning and work.
*I hereby authorize the release, either verbally or in writing, of any disability-related medical
information to GO Transit. I understand that this information may be used in conjunction with this
application when determining my eligibility for the Reduced Fare Program through GO Transit, and
will not be released without my written authorization.
I certify that, to the best of my knowledge, the information given on this application is true and
accurate. I understand that GO Transit will rely upon this information when determining eligibility
for the Reduced Fare Program. I understand that providing false or misleading information will
result in my eligibility being revoked. Allowing individuals, other than myself, to utilize this card
will also result in revocation.
Applicant’s Signature: ______________________________________________ Date: ______________
Reduced Fare Program Application
For Office Use Only
Date Issued: __________ Card Number: ________________________________________________ Staff Initials: _______
Page 2
Reduced Fare Program Application
Professional Verification
APPLICANT’S NAME: ____________________________________ DATE OF BIRTH:_____________
This page MUST be completed by a Licensed Professional (doctor, nurse, social worker) with a State-issued License. To
qualify for the GO Transit Reduced Fare Program, your patient/client (applicant listed above) must have a physical or
mental impairment that falls within the eligibility criteria listed below. Certain conditions do not qualify, i.e. pregnancy,
obesity, drug/alcohol addiction, controlled epilepsy. (If the applicant meets the eligibility criteria, complete and sign the
box below. If the applicant does not meet the eligibility criteria, check the box at the end of the form and sign on the line.)
Eligibility Criteria:
• Non-Ambulatory:
o Impairment which requires individual to use a wheelchair or similar mobility device.
• Semi-Ambulatory:
o Arthritis – American Rheumatism Association may be used as a guideline for the determination of disability; Therapeutic Grade III,
Function Class II, Anatomical State III, or worse is evidence of arthritic disability.
o Loss of Extremities – Anatomical deformity of or amputation of hand(s) and/or feet, or loss of major function.
o Cerebrovascular Accident – Ongoing debilitating effects following occurrence of CVA, or effects of Cerebral Palsy.
o Cardio-pulmonary – serious loss of heart or lung reserves as shown by X-ray, EKG, or other tests and in spite of medical treatment,
there is breathlessness, pain, or fatigue.
o Dialysis – individual who must use a kidney dialysis machine to sustain life.
o Other – list diagnosis and how it affects mobility: _________________________________________________________________________
_____________________________________________________________________________________________________________________
• Hearing Impairment:
o Legally Deaf – Hearing impairment that is bilateral and not correctable by hearing aid.
• Visual Impairment:
o Legally Blind – Visual Impairment that is bilateral and not correctable with lenses.
o Contraction of Visual Field – Persons whose widest diameter of visual field subtends an angular distance of 20 degrees, or less than
10 degrees from point of fixation.
o Low Vision – An individual has low vision, and whose visual acuity is in the range of 20/70 to 20/200 with best correction.
• Cognitive Impairment:
o Developmentally Disabled – Cognitive disability that originates before age 18.
o Adult Intellectual Disability
o Autism – Monotonously repetitive motor behavior with severe withdrawal, inappropriate response to stimuli, or very inadequate
social relationships.
o Schizophrenia
o Organic Brain Syndrome/Bi-Polar – Cognitive disturbance that requires boarding or home care, funded work activity or workshop.
• Neurological Disabilities:
o Cerebral Palsy – Impairment not controlled with medication.
o Multiple Sclerosis – Impairment not controlled with medication.
o Epilepsy – Grand Mal or Psychomotor; Persons who are seizure-free for period of six months do not qualify.
☐ Applicant’s impairment DOES NOT MEET any of the functional limitations listed above. Therefore, I cannot certify that the
applicant’s impairment meets the eligibility criteria for receiving GO Transit’s Reduced Fare Program ID Card.
______________________________________________________________________________________________________________________________________________________
Physician’s/Licensed Professional’s Signature Date
Please Print or Type: All information in this box MUST be provided by a State licensed professional (State-issued License)
____________________________________________________________________________________________________________________________________
Physician’s/Licensed Professional’s Name State-issued License # (Required)
____________________________________________________________________________________________________________________________________
Office Address City State Zip Phone Number
I certify that the applicant listed above is disabled as defined by the above criteria, and that the information I have provided is true and correct. I
am currently treating/servicing the applicant for one or more of the disabilities listed above.
____________________________________________________________________________________________________________________________________
Physician’s/Licensed Professional’s Signature Date