FARE MEDIA BY MAIL ORDER FORM
Send form to: Fare Media Program-101 Monroe Street, 5th Floor-Rockville, MD 20850 
Name: ________________________ Customer No. _____________ Address: _________________
City __________________ State ______ Zip_________  Daytime Telephone No. : ______________

Quantity	Description	Total Cost
	Monthly Pass @ $25   __________, __________, __________	$
	**Ride On Youth Cruiser Monthly Pass @ $10 (Proof of age required)	$
	Metrobus Weekly Pass @ $11 #___,#___.#___,#____	$
	*Disabled Metrobus Weekly Pass @ $6 #___,#___,#___	$
	*Senior Metrobus  Weekly Pass @ $6 #___,#___,#___	$
	7 Day Short Trip Pass @ $26.40 each	$
	7 Day Fast Pass @ $39.00 each	$
	One Day Rail Pass @ $7.80 (Valid after 9:30AM Mon-Fri & all day Weekends, Holidays)	$
	Metrorail Farecard @ $20.00	$
	*Disabled Metrorail Pass @ $10.00	$
	*Senior Metrorail Pass @ $10.00	$
	SmarTrip Card @$5.00	$
	* Senior/Disabled SmarTrip card @ $5.00	$
	FARE MEDIA TOTAL	$
	Add 5% handling fee	$
	SUBTOTAL	$
	Less new (unused) Metrocheks attached The back of Metrochek must be filled out	$
	TOTAL DUE	$

FAX ORDERS TO: 240-777-5881

* WMATA Senior ID or Medicare Card and photo ID required
** 18 Years and younger; proof of age required. Proof of age: Copy of birth certificate or passport
Method of Payment:
_____ Check (Make checks payable to Montgomery County Government)
_____Credit Card:_____VISA ____MasterCard Expiration Date: ______/_________
Account #: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

I authorize you to bill the above noted credit card for the goods/services indicated above. 
I agree to pay the above total in accordance with the card issuers agreement.

Signature required: ________________________________________________
If paying with a credit card, please change the name as it appears on the credit card.