MT
-
103 (1-12
)
APPLICATION
Pennsylvania
SENIOR CITIZEN TRANSIT
IDENTIFICATION CARD
DEPARTMENT
OF
TRANSPORTATION
FREE/REDUCED FARE
CARD NUMBER
TRANSIT
PROGRAMS FOR
SENIOR
CITIZENS
DATE OF APPLICATION
NAME OF APPLICANT (Last, First, Middle Initial)
ADDRESS (Street or Route)
(City or Post
(State)
(Zip Code)
Office)
MALE
SIGN HERE
HOME TELEPHONE NUMBER
DATE OF BIRTH
AGE
AREACOOE ______-______-________
FEMALE
X________________________________
THIS SECTION TO BE COMPLETED BY TRANSIT AGENCY
ACCEPTABLE PROOF OF AGE DOCUMENTS (ONE REQUIRED, CHECK AND INCLUDE APPLICABLE INFORMATION)
ARMED FORCES DISCHARGE/SEPARATION PAPERS – SEPARATION DATE___________________________________
BAPTISMAL CERTIFICATE-CHURCH'S NAME & ADDRESS__________________________________________________
BIRTH
CERTIFICATE-
NUMBER ________________________________________________________________________
–
PASSPORT/NATURALIZATION PAPERS
NUMBER________________________________________________________
PENNSYLVANIA IDENTIFICATION CARD
-
NUMBER ________________________________________________________
RESIDENT ALIEN CARD – NUMBER________________________________________________________________________
PACE IDENTIFICATION CARD – NUMBER___________________________________________________________________
PHOTO MOTOR VEHICLE OPERATOR’S LICENSE – NUMBER__________________________________________________
STATEMENT OF AGE FROM UNITED STATES SOCIAL SECURITY ADMINISTRATION
(ATTACH COPY TO THIS APPLICATION)
__________________________________________________________________________________ ____________________
PLEASE NOTE THAT ONLY THE ABOVE FORMS OF AGE DOCUMENTATION ARE ACCEPTABLE FOR THESE PROGRAMS
I DO HEREBY CERTIFY THAT I HAVE REVIEWED THE ABOVE AGE DOCUMENTATION AND THE
INFORMATION CONTAINED HEREIN IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE,
INFORMATION AND BELIEF.
SIGNATURE OF TRANSIT AGENCY REPRESENTATIVE CERTIFYING AGE DOCUMENTATION -DATE
PRINTED NAME OF ABOVE TRANSIT AGENCY REPRESENTATIVE
NAME OF TRANSIT AGENCY (Include Street or Route, City or Post Office, State, Zip Code)