Honored Citizen Application Form
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1
2Honored Citizen Application
TriMet Ticket Office: 701 SW 6th Avenue, Portland, OR 97204
503-962-2455 •
Hours: Monday–Friday 8:30 a.m.-5:30 p.m.
To use an Honored Citizen fare, a person must present one of the following when asked by TriMet personnel: Photo ID showing proof
of age 65 or older, a red, white and blue Medicare card with photo ID, or a TriMet Honored Citizen Photo Identification Card—issued after
completing this form. Application must be submitted in person along with government issued photo ID. Requires photo taken by TriMet.
Applicant information
(PLEASE PRINT LEGIBLY)
Name:
_____________________________________ , _______________________________________________
Last name
First name
Mailing address:
_____________________________________
__________________________
_______
__________
Street
City
State
Zip
Date of birth:
_____________________________________
Telephone number: ( _____ ) ______________________________
Email address: __________________________________
I am applying for a TriMet Honored Citizen ID Card.
This is my first ID card. Application must be submitted in person, requires photo taken by TriMet.
I need a replacement ID card; my card was lost, stolen, or damaged. $5 fee required.
I need to renew my expired card. $5 fee is required if renewing a card that was issued for up to 12 months. Application must
be submitted in person, requires photo taken by TriMet.
I am applying for a TriMet Honored Citizen Downtown Pass
$10 fee required. For details, the program description is available at or the TriMet Ticket Office.
Note: Fee payable by cash, check, money order or credit/debit card.
Certification of eligibility section
(Check only one box below)
To qualify under this type of eligibility you must have the health care provider certification section
Health care provider
on the reverse side completed. Please return this application within 30 days of the date completed
certification
by the health care provider.
Attach benefit verification to this application.
Social Security
Requires TriMet issued verification stamp on reverse side.
Certified agency
65 years of age or older. Must present government issued photo ID.
Senior (65+)
Attach VA documentation to this application.
Disabled veteran
30 days maximum. Visitor must show Transit Agency issued ID card to qualify.
Visitor ID
City and state of agency ___________________________________________________________
To qualify present Medicare card and government issued photo ID.
Medicare card
I agree to release the information I am sending to TriMet for the purpose of making this application for an Honored Citizen ID Card.
I certify that the information I provide concerning my application is true and correct. I understand that TriMet reserves the right to
require proof of disability in addition to this form. If applying for the Honored Citizen Downtown Pass/ID Card, I agree to abide by the
terms of the program description, and photo ID card. I give my consent for TriMet, or a TriMet Designated Administrative Agency**, to
take and retain a copy of my photo. TriMet will not accept a photocopy or fax of this form.
Signature of applicant _________________________________________________ Date ______________________________
140613 • 9/14
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