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EXHIBIT 5 <br />24 <br />N E COUNTY <br />NORTH CAR01,TNA <br />APPLICANT AGREEMENT <br />I agree that, if I am certified for Orange Public Transportation ADA Paratransit, I will pay the exact <br />fare, if required, for each trip. I agree to notify the office of any changes in my status that may affect <br />my eligibility to use the service. I also understand that failure to adhere to the policies and <br />procedures will be grounds for revoking my application and the right to participate in the program. <br />I understand and agree to hold Orange County and Orange Public Transportation harmless against <br />all claims or liability for damages to any person, property, or personal injury occurring as a result of <br />my failure to equip or maintain the safety of the adaptive equipment or certified guide /service animal <br />that I require for mobility. <br />I hereby authorize the release of verification information and any additional information to Orange <br />County /Orange Public Transportation for the purpose of evaluating my eligibility to participate in the <br />Program. <br />I certify that the information provided in this application is true and correct. <br />Signature Date <br />If someone assisted you in completing this application, please provide his /her information <br />and signature below: <br />NAME: DAYTIME PHONE: <br />ADDRESS: <br />Street Apt. # <br />City State Zip <br />Signature Date <br />