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2. FACE MASK EXEMPTION REQUEST
   Please submit this form to request a face mask exemption accommodation due to a medical condition and/or disability. You must submit this form and documentation from your medical provider supplying information on why a face mask exemption is necessary. All questions must be answered, and electronic signature is required. You will be required to submit a fully completed Healthcare Provider Verification with your application. Incomplete requests will not be considered. Once your request has been approved, you will receive a PART Mask Exemption Card. This card should be shown to the driver prior to boarding any PART Express vehicle. You may also be requested to show this card while at any PART facility.
4. Download the Healthcare Provider Verification Form
   Healthcare Provider Verification Form
6. First Name
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address
18. Medical Conditon*
    Please identify and describe the medical condition and/or disability that is a basis for your request for a mask exemption accommodation by the transit system (Please be specific):
20. Mask Impact*
    Please describe how a face mask could impact your daily living while riding a transit vehicle or are in a transit facility and why an exemption accommodation is necessary:
22. Healthcare Provider Verification
    Upload a fully completed and signed version of your Healthcare Provider Verification form.
24. E-Signature
    By typing your name here, you are providing an electronic signature verifying the information you have provided is accurate. You also acknowledge the rules and regulations of PARTs Mask Exemption program.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field