City of Alexandria, Virginia

Department of Community and Human Services

Division of Aging and Adult Services

Purchase of Senior Taxi Yellow Card Discount Fares Application

Date: ______

I would like to purchase the following value of discount fares (please choose only one): Fare Choices:

Check one / Value of
taxi fares / Cost to
Senior Taxi Rider
£ / $150 / $30
£ / $ 80 / $18

I understand that I may purchase discount fares four times a year following this schedule:

Discount fares can be purchased one time during each of these time frames:
June 16 - September 15
September 16 - December 15
December 16 - March 15
March 16 - June 15

Name:

Address:

Phone: Email Address:

I understand that this program is contingent on available funding and that the City reserves the right to decline requests for purchase of discounted fares if the balance on the Senior Taxi Yellow Card is excessively high. If purchase is approved, the value will be electronically added to your Senior Taxi Yellow Card, so please do not throw your Yellow Card away. No refunds will be given once a purchase is approved. For more information, please call 703.746.5999.

Signature:

Please mail form and payment of check or money order made payable to the City of Alexandria to the address below. Cash payments will not be accepted.

Senior Taxi Yellow Card Program

Division of Aging and Adult Services

4401 Ford Avenue, Suite 103

Alexandria, VA 22302

For Office Use Only

Purchase for $______in Taxi Fares ______quarter of FY 2016

Date entered into PeerPlace: ______PeerPlace Operator:

Payment method: Check# Money Order # ______Amount: $

Other:

Revised 5-11-2016