Registration

Name:

Year of Birth:

Address:

Town/City:

Postal Code:

Phone number:

# People in Household:

Email address:

What is your yearly household income? (please include all sources):

Why are you applying for the Fare Assistance Program? (This information is used to determine financial assistance):

I certify that the information I have provided on this application is true and accurate .

I understand that East Hants & Area Community Rider reserves the right to request more information and supporting documents, and to provide or deny subsidy at their discretion based on current policies and funds available.

I accept these conditions:

Date: