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 hereby make application for a reduced fare
I.D. card for use on State subsidized transit services. I understand
that these privileges may be limited as to duration and are
revocable at any time. I do not have a
Medicare card, so I need a separate senior/disabled I.D. card.
Application processing will take 2 to 4 weeks.
Note: Personal
checks must have the signer's name and address imprinted on the
check in order to be accepted by CTTRANSIT.
Mr. 
Mrs.
Miss
Ms.
Last
Name: 
First Name:
MI:
Permanent Street Address:
Apt.#:
City or Town/State/Zip Code:
Date of Birth:
Phone:
Written Signature of Applicant or
Guardian:
I am a "person with a
disability"; within the meaning of that term as set forth in
the instructions. In support of this application, I submit below the
opinion of a physician as required by this instruction.
Physician's
Statement: I have examined the applicant identified above, and
it is my opinion that (s)he is a person with a disability within the
meaning of that term as defined by the Federal Transit
Administration, previously note herein.
I estimate that the
duration of the impairment will be:
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Temporary (over 3
months but under 12 months) - A one-year card
will be issued. (see "new applicant" information
above).
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Permanent - A
permanent card will be issued.
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Physician's
signature date
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 and do not have a Medicare card. In support of
this, I submit below the certification as required by these
instructions.
Notary's
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.
Notary/Town
Clerk/Registrar of
Voters Date
Seal/Stamp
Required
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