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To apply, please fill out this application and upload supporting documents. If approved, you will receive a letter from the Finance Department and the service will become effective within sixty (60) days after the date of approval. If denied, you will receive a letter stating the reason for the disapproval. If you have any questions, please contact Maggie Poon at email@example.com or call (626) 307-1338.
* If using a doctor's note, please attach a recent certification signed by your physician
I understand that I am required to renew my certification annually and notify the City of any change in information to maintain my eligibility. Failure to do so may result in my removal from this program. I agree that by completing this form and submitting it to the City in an electronic format, such as email, it will have the same legal effect as a form submitted by U.S. Mail or in-person. I certify, under penalty of perjury under the laws of the state of California, that the information I have provided in this application is true and correct.
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