OFFICE USE ONLY: Intake Date Transit Agency Employee Name 01/2016
Complete and submit this application to obtain a free Senior Clipper card. All applications must be accompanied by a copy of proof-of-age documentation. Cards are available for adults 65 and older. Step 1: CARDHOLDER CONTACT INFORMATION All ﬁelds in Step 1 are required except email. First Name Middle Initial Last Name Address Apt # City State Zip Code Day Phone Email Address (optional) Step 2: CARDHOLDER PROOF-OF-AGE DOCUMENT
Check the one document you are submitting and write its number below. Only send photocopies. Do not send original documents.
Birth certiﬁcate or passport
State-issued ID card or driver’s license
Permanent resident card (“Green Card”)
Matricula consular/consular ID card
SF City ID card
Military ID card with date of birth
Medical beneﬁt card with date of birth
Your Document’s Number Date of Birth (MM/DD/YYYY) Step 4: SIGNATURE
By signing, I attest that the information on this application is true and correct. Signature Date Step 5: SUBMIT APPLICATION
MAIL your application form and a copy of your proof-of-age document to: Clipper Youth/Senior Applications, PO Box 318, Concord, CA 94522-0318. Do not send originals, as documents will not be returned. Or EMAIL scans or photos of your application form and your proof-of-age document to firstname.lastname@example.org.
Or FAX your application form and proof-of-age document to 877-***-****. Please allow 7 business days for delivery.
Step 3: CLIPPER ACCOUNT INFORMATION
In which one of the following languages would you
prefer to receive your Clipper information?
English Spanish Chinese
To provide an additional level of security when
accessing your card information, Clipper requires you to provide an answer to one of the following:
Mother’s Maiden Name City of Birth Note: You will be asked this question each time you contact Clipper Customer Service to access your card information in person or via phone or email.