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2. 
3. APPLICATION FOR REDUCED FARE
5. RoadRUNNER offers half fare to persons with disabilities, Medicare recipients, and senior citizens age 60 and older. Half fare is available on RoadRUNNER’s fixed-route service. Persons with disabilities must have a valid I.D. card issued by RoadRUNNER or other public transportation system. The information obtained in this application will only be used to determine your eligibility for RoadRUNNER’s Reduced Fare Program. Please complete the following:
7. Name of Applicant
9. Address
11. Email Address
12. Phone Number
14. The person named below is familiar with my condition or disability and is authorized to provide information required to verify my disability status:
16. Name
17. Title
19. Address
21. City
22. State
23. Zip Code
25. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
27. Electronic Signature of Applicant
28. Date
    Date
30. SENIOR CITIZENS: Proof of age (60 years or older) or Medicare Card required.
32. CERTIFICATION
34. First Name
35. Last Name
37. I certify that according to my (check those that apply)

    1. Personal examination
    2. Office records
    3. School records

    1. Agency records
    2. Other
39. The disability is

    1. Permanent

    1. Temporary
40. If temporary add estimated duration in months
42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Electronic Signature
45. Date
    Date
47. Agency
49. Address
50. Phone Number
52. This application can be made available in alternative formats by calling (575) 541-2500
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field