APPLICATION FOR REDUCED FARE PRIVILEGES & PHOTO I.D. CARD for STATE SUBSIDIZED TRANSIT SERVICES

I hereby make application for a reduced fare I.D. card for use on State subsidized transit services. I understand that these privileges may be limited as to duration and are revocable at any time. I do not have a Medicare card, so I need a separate senior/disabled I.D. card. Application processing will take 2 to 4 weeks.

Note: Personal checks must have the signer's name and address imprinted on the check in order to be accepted by CTTRANSIT.

New Applicant:
	I have attached a recent passport type color photo (size 1 1/4" x 1 1/4") of my face (top of head and bottom of chin must be showing) for use in the preparation of my I.D. card. The photo will not be returned. I have printed my name on the back of the picture.
	I have enclosed a $5.00 check/money order for a new card, payable to CTTRANSIT. Do NOT enclose cash. See above note for check requirement.
Replacement Card Requested (lost, stolen or damaged cards):
	I have attached a recent passport type color photo (size 1 1/4" x 1 1/4") of my face (top of head and bottom of chin must be showing). The photo will not be returned I have printed my name on the back of the picture.
	I have enclosed a $10.00 check/money order for a replacement card, payable to CTTRANSIT. Do NOT enclose cash. See above note for check requirement.
Renewal of Expiring Card:
	I have enclosed a $5.00 check/money order for the renewal of my temporary card payable to CTTRANSIT. Do NOT enclose cash. See above note for check requirement.
Expiration date of my card is: Card Number:

Mr.            Mrs.            Miss            Ms. 

Last Name:  

First Name:  

MI:  

Permanent Street Address:  

Apt.#:  

City or Town/State/Zip Code:  

Date of Birth:  

Phone:  

Written Signature of Applicant or Guardian:

For Disabled Certification

I am a "person with a disability"; within the meaning of that term as set forth in the instructions. In support of this application, I submit below the opinion of a physician as required by this instruction.

Physician's Statement: I have examined the applicant identified above, and it is my opinion that (s)he is a person with a disability within the meaning of that term as defined by the Federal Transit Administration, previously note herein.

I estimate that the duration of the impairment will be:

	Temporary (over 3 months but under 12 months) - A one-year card will be issued. Reapplication is required for a new card (see "new applicant" information above).
	Permanent - A permanent card will be issued.

Physician's signature date



Physician's printed name                               phone number



Physician's license number

For Senior Citizen Certification

I am 65 years of age or older as of the date of this application and do not have a Medicare card. In support of this, I submit below the certification as required by these instructions.

Notary's Statement: I have seen the applicant identified above and the applicant has shown me:

Form of ID (Birth certificate/alien registration card, etc.)

I am attesting to the fact that the applicant is 65 years of age or older.

Notary/Town Clerk/Registrar of Voters                     Date

Seal/Stamp Required