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Taxdeductible donations are greatly appreciated. For more information please visit us online at or contact us at shareafareinc inebraska.com HU U SHARE A FARE APPLICATION FORM APPLICATION INFORMATION PLEASE PRINT CLEARLY LAST NAME FIRST NAME DATE OF BIRTH PHONE ADDRESS CITY STATE ZIP CODE CHECK CAB PREFERENCE HAPPY CAB SAFEWAY CAB THIS SECTION TO BE COMPLETED BY CERTIFYING AUTHORITY DOCTOR NURSE OPTOMETRIST REHABILITATION COUNSELOR Low Vision Vis.

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