OUTBoard agenda 021815 - Laserfiche WebLink

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APPLICANT AGREEMENT I agree that, if I am certified for Orange Public Transportation ADA Paratransit, I will pay the exact fare, if required, for each trip. I agree to notify the office of any changes in my status that may affect my eligibility to use the service. I also understand that failure to adhere to the policies and procedures will be grounds for revoking my application and the right to participate in the program. I understand and agree to hold Orange County and Orange Public Transportation harmless against all claims or liability for damages to any person, property, or personal injury occurring as a result of my failure to equip or maintain the safety of the adaptive equipment or certified guide/service animal that I require for mobility. I hereby authorize the release of verification information and any additional information to Orange County/Orange Public Transportation for the purpose of evaluating my eligibility to participate in the Program. I certify that the information provided in this application is true and correct. _________________________________________________________________________ Signature Date If someone assisted you in completing this application, please provide his/her information and signature below: NAME:___________________________________ DAYTIME PHONE:________________ ADDRESS:_______________________________________________________________ Street_________________________________ Apt. # ___________________ ________________________________________________________________ City State Zip _________________________________________________________________________ Signature Date 29EXHIBIT 5 ReturntoAgenda