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OFFICE USE ONLY: Intake Date Transit Agency Employee Name 01/2016

SENIOR APPLICATION

APPLICATION INSTRUCTIONS

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 ***************@***********.***.

Or FAX your application form and proof-of-age document to 877-***-****. Please allow 7 business days for delivery.

You may also apply in person at a Clipper Customer Service Center or participating transit partner location to get a card immediately. See full list of locations at clippercard.com/discounts. Questions? Call Clipper Customer Service at 877-***-****. Please view the Clipper Privacy Policy at

clippercard.com/privacy.

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.

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