MiWay Affordable Transit Pilot Program
Application Form
SECTION 1
APPLICANT INFORMATION
Last Name
First Name
Age
Gender (Optional)
Male
Female
Other
Address
City
Postal Code
Cell Phone Number
SECTION 2
Last Name
SECTION 3
Prov.
Telephone Number
Email
FAMILY INFORMATION (Please list all individuals living in your household. Dependent(s) over 18
must apply on their own.)
First Name
Age Gender (Optional)
Requires Pass
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
Male
Female
Other
Yes
No
ELIGIBILITY (To participate you must have a household income less than the amounts listed.
Please provide 2014 or 2015 Canada Revenue Agency Notice of Assessment (Line
236) and proof of Mississauga address)
Low Income Measured (LIM) Household Thresholds
1 Person
$19,930.00
2 Persons
$28,185.28
3 Persons
$34,519.77
4 Persons
$39,860.00
5 Persons
$44,564.83
6 Persons
$48,818.33
7 Persons or more
$52,729.82
Notice with Respect to the Collection of Personal Information
(Municipal Freedom of Information and Protection of Privacy Act)
The collection of personal Information in this form is pursuant to the Municipal Freedom of Information and Protection of
Privacy Act. The information is collected by the Region of Peel under the authority of the Municipal Act, 2001 and will be
used for the purpose of administering the MiWay Affordable Transit Pilot Program, including determining eligibility and
program evaluation (transit usage surveys and focus groups). For more information contact the MiWay Affordable Transit
Staff at (905)791-7800 Ext. 8703 or email [email protected]
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MiWay Affordable Transit Pilot Program
Application Form
SECTION 4
HOW DID YOU HEAR ABOUT THE PROGRAM?
Flyer
Community Agency (please specify)
Word of Mouth
Newspaper (please specify)
Poster/Ad
Social Media (please specify)
Newsletter
Other (please specify)
Website
SECTION 5
APPLICATION SIGNATURES
I certify that the information set forth in this application is true and complete to the best of my knowledge. I
understand that any falsified statements on this application or inability to provide documentation upon
request can result in termination from the program. I understand that the information provided may be
utilized for evaluation/research purposes and I may be contacted by email/post mail/phone to provide
feedback during participation in the MiWay Affordable Transit Pilot Program. I understand that the Region of
Peel will not be liable for damages arising from but in no way limited to, the transmission of confidential
information over the internet, by fax and/or email.
Applicant Signature
Date
e
Please contact the Region of Peel's MiWay Affordable Transit Program information line at 905-791- 7800
ext.8703 or e mail at [email protected] if you have any questions or require assistance
with this application.
This application and all supporting documents can be sent by fax, email or in person.
Fax to 905-450-5757
Attn: MiWay Affordable Transit Program
Email at [email protected]
If you would like to submit in person please call 905-791-7800 Ext. 8703 or email
[email protected]
Please do not submit application to MiWay customer service, your application will not be received.
FOR REGION OF PEEL OFFICE USE ONLY
Eligibility Documentation
Documentation Date
(MM/DD/YY)
/
/
/
/
Notice with Respect to the Collection of Personal Information
(Municipal Freedom of Information and Protection of Privacy Act)
The collection of personal Information in this form is pursuant to the Municipal Freedom of Information and Protection of
Privacy Act. The information is collected by the Region of Peel under the authority of the Municipal Act, 2001 and will be
used for the purpose of administering the MiWay Affordable Transit Pilot Program, including determining eligibility and
program evaluation (transit usage surveys and focus groups). For more information contact the MiWay Affordable Transit
Staff at (905)791-7800 Ext. 8703 or email [email protected]
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V-10-701