Annual Premium Transitchek Replacement Metrocard Certification Form printable pdf download

NEW YORK CITY HEALTH AND HOSPITALS CORPORATION

TRANSIT BENEFIT PROGRAM

ANNUAL PREMIUM TRANSITCHEK REPLACEMENT METROCARD

CERTIFICATION FORM

UNDELIVERED, DAMAGED, AND LOST OR STOLEN METROCARD

You must bring this form to your Payroll Department

EMPLOYEE ID NUMBER:

NAME:

_________/______/_________

______________________________________________________________

LAST

FIRST

FACILITY:

WORK TELEPHONE NUMBER:

___________________________________________________

(_______)___________-_______________

CERTIFICATION:

I certify that (check one):

I did not receive my Annual Premium TransitChek MetroCard.

My Annual Premium TransitChek MetroCard is damaged and does not work.

(This Certification must be accompanied by your Annual Premium TransitChek MetroCard)

Please explain here _________________________________________________________________________________

_________________________________________________________________________________________________

I lost my Annual Premium TransitChek MetroCard.

My Annual Premium TransitChek MetroCard was stolen.

I further certify that the information I have provided is accurate and true to the best of my knowledge.

I will pick up replacement Annual Premium TransitChek MetroCard at my facility’ s Payroll Department.

:_________________________________________

: _____________________

SIGNATURE

DATE

… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ...

I certify that I have received the replacement Annual Premium TransitChek MetroCard # __________________________________

:_________________________________________

: _____________________

SIGNATURE

DATE

CORPORATE PAYROLL OPERATIONS USE ONLY

EMPLOYEE ID NUMBER:

__________________________________________

REPLACEMENT METROCARD NUMBER: ___________________________________

DATE REPLACEMENT ISSUED: ___________________________________________

ISSUED BY: ___________________________________________________________

___________________________________________________________

SIGNATURE

PICKED UP BY: ___________________________________________________

PRINT NAME

___________________________________________________

SIGNATURE

Annual Premium Transitchek Replacement Metrocard Certification Form

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