Senior Citizen Appreciation Pass Program Application (Page 2 of 2) in pdf

Senior Citizen Appreciation Pass Program Application Page 2

Fairbanks North Star Borough

809 Pioneer Road • PO Box 71267 • Fairbanks, Alaska 99707-1267 • (907) 459-1000 FAX 459-1100

Emergency Card Information

Name: First_______________ Mi.__

_ Last:___________

Date of Birth: _______/_

__/_________

Spouse: ___________

_____________

Home Address: _____

_____________________ City:__________________ State: ______

Zip Code:__________-_______

Phone: Day_________________ Night:______________

Contact Person Not Living with You:

1) Name:___________________ Phone:______________

2) Name:___________________ Phone:______________

3) Name:___________________ Phone:______________

Doctor’s Name: ___________________

Phone: ________

Allergies:

___________________________________________________________________________________

______________________________________________

______

Diabetic:

Yes________ No_______

Heart Disease:

Yes_______ No________

This Emergency Information will be printed on the back of your Senior Appreciation Pass. If you

want only the Emergency Information, your signature on the front of this form is required.

You may submit a photo with your application or stop at the FNSB Administration Center Front

Desk to have your photo taken and have your card printed.

Senior Citizen Appreciation Pass Program Application Page 2