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.
||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.
Requested (lost, stolen or damaged cards):
||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.
Permanent Street Address:
City or Town/State/Zip Code:
Date of Birth:
Written Signature of Applicant or
I am a "person with a disability" as described in the definition in the instructions.
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:
||Temporary (over 3
months but under 12 months) - A one-year card
will be issued. (see "new applicant" information
||Permanent - A
permanent card will be issued.
Physician's printed name phone number
Physician's license number
I am 65 years of age or older as of the date of this application.
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.