Use this form for the Medical Assistance Transportation Program. Please complete all fields below.  Use the TAB key to navigate the form. General Information: Your Full Name       First                 MI                 Last Street Address 1 Street Address 2 City State Zip Code Home Telephone Work Telephone Your E-mail County of Residence Social Security Number - - Date of Birth: Month Day Year (Example: 02 10 1959) To avoid any delay in processing your application, please remember to submit a copy of your medical card. Mail or deliver to: Fayette Area Coordinated Transportation (FACT) 825 Airport Road Lemont Furnace, PA 15456 Your application will not be completed until this document is received in our office.   Home  •  About  •  Schedules  •  Medical Assistance  •  FAQs  •  Shared Ride Area Links  •  Management  •  ADA Transportation  •  News  •  Contact [ 汉语 ] [ Deutsch ] [ 日本語 ] [ 한국어 ] [ Français ] [ Italiano ] [ Português ] [ Español ] Instant Translation by AltaVista Babelfish This site designed and maintained by Webguy Productions