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PRINTABLE Application For Reduced Fare Privileges & Photo I.D. Card For State Subsidized Transit Services

Please print out this application, fill it out and mail it to: CTTRANSIT. Attn: Senior/Disabled Representative. P.O. Box 66 Hartford, CT 06141-0066

I am applying for a Senior/Disabled Reduced Fare Transit ID Card for use on state subsidized transit services.

Note: Make checks payable to CTTRANSIT. Personal checks must have the applicant's name and address on the check. Do NOT send cash. The photo will not be returned. Application processing will take up to two (2) weeks.


New Applicant:
Check Box Graphic I have enclosed a recent color photo of my face (top of head and bottom of chin must be showing) for use in the preparation of my I.D. card. I have printed my name on the back of the photo. I have enclosed a $5.00 check/money order for a new card.
Replacement Card Requested (lost, stolen or damaged cards):
Check Box Graphic I have enclosed a recent color photo of my face (top of head and bottom of chin must be showing) for use in preparation of my ID card. I have printed my name on the back of the photo. I have enclosed a $10.00 check/money order for a replacement card.

Mr. Check Box Graphic           Mrs. Check Box Graphic           Miss Check Box Graphic           Ms. Check Box Graphic

Last Name:  Line Graphic

First Name:  Line Graphic

MI:  Line Graphic

Permanent Street Address:  Line Graphic


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Apt.#:  Line Graphic

City or Town/State/Zip Code:  Line Graphic

Date of Birth:  Line Graphic

Phone:  Line Graphic

e-mail:  Line Graphic

Written Signature of Applicant or Guardian:


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Please fill out Either Section A--OR--Section B but not both.


SECTION A: Disabled Certification
I am a "person with a disability" as described in the definition in the instructions.

Physician's Statement:I have examined the applicant identified above, and it is my opinion that (s)he is a person with a disability as described in the definition in the instructions

I estimate that the duration of the impairment will be:

Check Box Graphic Temporary (over 3 months but under 12 months) - A one-year card will be issued. (see "new applicant" information above).
Check Box Graphic Permanent - A permanent card will be issued.


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Physician's signature date


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Physician's printed name                               phone number


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Physician's license number


SECTION B: Senior Citizen Certification
I am 65 years of age or older as of the date of this application.

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


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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.


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Notary/Town Clerk/Registrar of Voters                     Date

Seal/Stamp Required

 

 

 

 

 

 
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