County of Hawaii Mass Transportation Agency
Application Form for Free Ride Pass on the Basis of Disability
Applicant?s Name _____________________
___ ___________________
_____
Last
First
M.I.
Mailing Address _____________________________ _________________ ______ ____________
P.O. Box or Street
City
State Zip Code
Phone No.: ________________________ Identification: (Circle One) HI Driver?s License _ HI ID _ Other
ID (specify): _____________________ Date of Birth _________________ Gender:
?
Male
?
Female
1. I am applying for a Hele-On Bus Free Ride Pass because I have a physical or mental impairment that
substantially limits one or more major life activities. (Major life activities include walking, breathing,
standing, seeing, hearing, caring for oneself, learning, etc.) Yes ____ No ____
2. My condition is ___ Permanent
___ Temporary
_____________________________________________________________________________
If temporary, please note duration above.
3.
I require a Personal Care Attendant (PCA) to accompany me when I travel:
___
Yes ___No
If
YES, please list the name(s) of your PCA(s):
______________________________________________
______________________________________________
Note:
Only one PCA is eligible to ride the Hele-On Bus for free when accompanying you.
In order for us to evaluate your application for a Free Ride Pass, you must have your Licensed Practicing
Physician certify that you are eligible for this program. Once the information on the reverse side of this page is
completed by your physician, the completed form must be submitted to the Mass Transit Agency for rocessing.
Terms of Usage and Release of Medical Information
I declare under penalties of penal law that the statements contained herein are to the best of my knowledge
true and accurate and that I have not knowingly given a false statement or given information which I know to
be false. I have read and understand the terms of Free Pass Usage below and I agree to abide by them.
I also authorize my physician to release medical information necessary to process this application. I
understand that information regarding my disability will be used solely to determine my eligibility for free
transportation services.
I understand that the Free Ride Pass cannot be used by anyone other than me. The bus pass must be visible
to the Hele-On Bus operator when I board the bus. If I lose my Free Ride Pass, I must notify the Mass Transit
Agency immediately. If my Free Ride Pass is lost or stolen, it cannot be used by anyone else. If it is found
and misused, the user will be fined. The Free Ride Pass will be valid for ______ (how long)? I must reapply to
be eligible for this program, if available, prior to expiration of my Free Ride Pass.
Applicant?s (or Authorized Representative?s) Signature:
____________________________________________
Date:
______________________
County of Hawaii Mass Transportation Agency
Application Form for Free Ride Pass on the Basis of Disability
Certification by Licensed Practicing Physician
This page must be completed by a licensing practicing physician (as defined under HRS 453, 455, 460 and
463E).
The physician must certify that the individual has a physical or mental impairment that substantially limits one
or more major life activities. Major life activities include caring for oneself, breathing, walking, seeing, hearing,
learning, etc. The Mass Transit Agency will review this certification to determine the applicant?s eligibility for
the Free Ride Pass.
I certify that ___________________________ has a physical or mental impairment that substantially limits one
or more major life activities.
Duration of Disability: (Please check the appropriate box below)
?
I certify that this impairment is long term (expected to last at least ______ years).
?
I certify that this impairment is temporary (less than 6 months in nature).
Physician Please Read Carefully
I understand that per HRS 291, Part III if I as a physician fraudulently verify that ________________________
Applicant?s Name
is a person with a disability to enable the applicant to obtain a Free Ride Pass on the Basis of Disability, I shall
be guilty of a petty misdeameanor and each fraudulent verification shall constitute a separate offense.
Physician?s Name: _________________________ __________________________ ________
Last
First
M.I.
Mailing Address: __________________________________
___________ _______
______
Street/PO
Box
City
State
Zip
Date: ______________
Phone Number: ____________
Medical License No. ______________
For program integrity, the Mass Transit Agency will conduct random checks to verify the authenticity of
certifications.
NOTICE TO APPLICANT:
Please send the completed application form to :
County of Hawaii Mass Transit Agency
25 Aupuni Street
Hilo, HI 96720
Telephone: (808)961-8744
If any information is missing, the form will be returned to you. You will be notified of our determination within
21 days of receiving your completed application. Your pass will be mailed to you (?) In the meantime,
when riding the Hele-On Bus, you must pay the bus fare until you receive the bus pass.