Do you have a current Transit Plus Card? Yes No

Expired within 6 months? Yes No

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TRANSIT PLUS ELIGIBILITY APPLICATION
If you need this application or other materials in an alternative format (braille, etc.), please call (414) 343-1700.
  1. Last Name ________________________ First Name _____________________ Middle Initial _________

  2. Address _____________________________________________________________________________
                                            Street                               Apt.#                                City                                         State                               Zip
  3. Social Security Number ____________________ Date of Birth ____________ Gender _______________

  4. Phone ______________________________________________________________________________

  5. Guardian/Alternate Mailing Address (complete only if all mail should be sent to this address)

    _____________________________________________________________________________________                                  Name                                                  Phone _____________________________________________________________________________________                                  Street                               Apt.#                                City                                         State                               Zip

PLEASE NOTIFY TRANSIT PLUS WHEN YOU MOVE. SERVICE COULD BE INTERUPTED
IF YOU DO NOT NOTIFY US.

  1. Do you use any of the following mobility aids?

    Cane                         Crutches                Walker
    Powered Wheelchair Manual Wheelchair Oversized Wheelchair
    Oxygen                     Powered Scooter    Dog Guide/Service Animal

    Other ________________________________________

  2. When do you use your mobility aids? Be specific (always, indoors, outdoors, hospital, etc.).

    _____________________________________________________________________________________

    _____________________________________________________________________________________

  3. Have you ever used Milwaukee County Transit System (city bus)? Yes No

    If yes, under what circumstances?___________________________________________________________

    _____________________________________________________________________________________

  4. Do you have any barriers such as steps or firedoors, etc. at your home or routine destinations that limit or stop you
    from reaching the exterior door, or, do you have more than one consecutive step to cross if you are in a wheelchair
    or scooter? ** Yes No

**TRANSIT PLUS DRIVERS CAN PROVIDE ASSISTANCE UP TO AND INCLUDING ONE STEP AND THROUGH THE BUILDING'S EXTERIOR DOOR.

  1. Do you require a personal care attendant when you travel? Yes No

  2. Do you require a personal care attendant when there is an architectural barrier such as getting up/down
    more than one consecutive step or getting to your destination such as your doctor's office, etc.
    Yes No

  3. I signify that the above information is true and accurate.

    _______________________________________         _________________________________________
    Applicant Signature                                              Date                                     Guardian (if applicable)                                                  Date

  4. Authorization For Release of Additional Medical Information, if Deemed Necessary:
    I hereby authorize the release of any of my disability-related medical information, either verbal or written, to Transit
    Plus. I understand that this information may not be used in determining my eligibility for services and will not be
    further released without my written authorization.

    _______________________________________         _________________________________________
    Applicant Signature                                              Date                                     Guardian/Power of Attorney                                             Date

ACTION STEPS:
  1. Call 343-1700 to schedule your in-person assessment appointment. TTD# is 343-1704.
  2. Please bring the following documents to your assessment. You may not be granted eligibility without them.
    1. This application fully completed.
    2. A letter on your Doctor's or Agency letterhead that includes:
      1. diagnosis (name) of illness or disability
      2. the ICDC code, if available
      3. the signature of a licensed medical professional including a Wisconsin medical license number
    3. A current form of photo identification
*Please arrive 10 minutes before your appointment with your completed forms.

The Transit Plus office is located at 1942 N. 17th St., Milwaukee, WI 53205, in the Milwaukee County Transit
System's Administration Building on ground level. Parking is available in the parking lot just outside the
building. (Fax number: 414-343-1787)

FOR TRANSIT PLUS USE ONLY
Receipt of                                                                                                       Request                                                 Appeal
APLICATION DATE: __________ PHOTO DATE: __________ APPEAL DATE: ____________ HEARING DATE ___________