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40 <br /> ORANGE COUNTY <br /> NORTH CAROLINA <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 />