CLIPPER YOUTH AND SENIOR APPLICATION

1 YOUTH AND SENIOR APPLICATION . APPLICATION INSTRUCTIONS. Complete and submit this APPLICATION to obtain a free YOUTH or SENIOR CLIPPER card. All applications must be submitted with a copy of proof-of-age documentation. DISCOUNTED FARES. YOUTH and SENIOR CLIPPER cards calculate discounted fares based on age and eligibility. Cards are available for YOUTH 5 to 18 and seniors 65 and over. 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: CLIPPER ACCOUNT INFORMATION Step 3: CARDHOLDER PROOF-OF-AGE DOCUMENT. What type of card are you applying for? Check the one document you are submitting and write its number below. Only send photocopies. YOUTH CLIPPER Card (5-18). Do not send original documents. SENIOR CLIPPER Card (65 and over) Birth certificate or passport State-issued ID card or driver's license For your protection, CLIPPER requires you to provide Permanent resident card ( Green Card ).

2 One of the following: Matricula consular/consular ID card Mother's Maiden Name SF City ID card Student ID card with date of birth City of Birth Military ID or dependent card with date of birth Note: You will be asked this question each time you contact Medical benefit card with date of birth CLIPPER Customer Service to access your card information in person or via phone or email. Your Document's #. Date of Birth (MM/DD/YYYY). Step 4: SIGNATURE Signature is required. By signing, I attest that the information on this APPLICATION is true and correct. Cardholder or Parent/Guardian 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 Please allow 7 business days for delivery.

3 Need a card right away? Apply in person at a staffed location. Visit for a list of staffed locations. Questions? Call CLIPPER Customer Service at Please view the CLIPPER Privacy Policy at OFFICE USE ONLY: Intake Date _____ Transit Agency _____ Employee Name _____. 10/2018.