HUMAN SERVICE AGENCY Certification Application

HUMAN SERVICE AGENCY Certification Application

Thank you for your interest in purchasing Pierce Transit Tickets and Passes for your clients. Please provide the requested information and answer the following questions.
Agency Name*
Primary Contact Name*

First NameLast Name
Primary Contact Name*
Address

Mailing Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Fax
1. Is the above listed organization a federal, state or local government agency or other organization that provides human services to its clients?*

Yes. Please continue to question 2.No. Your organization does not qualify.
2. Please check the primary purpose(s) of services you provide to members of the public (check all that apply):*

Prevention and treatment of illnesses and substance abuse.Children and family services.Domestic violence prevention and services.Services and programs which provide support to low income, senior, and disabled populations, such as housing, shelter, food, childcare, social security and employment programs.None of the above. Your organization does not qualify.
Other primary purpose, please describe here:
3. Is your organization tax-exempt under the IRS subsection 501(c)3?*

Yes. You may qualify for a discount. Provide your Employer Identification Number or Tax Identification Number below. Your 501(c)3 status may be verified periodically.No. Although your organization does not qualify for a discount, you may still submit this form to purchase Tickets and Passes for your clients at full price.
If you answered yes to the previous question please provide your Employer Identification Number or Tax Identification Number: *
Upload a copy of your IRS 501(c)3 Determination Letter here.*

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The following rules apply to Human Service Agencies approved to purchase magnetic stripe Pierce Transit One Ride tickets and/or All Day Passes:
- The Human Service Agency may not re-sell tickets
- Tickets and passes must be given to the Agency's clients free of charge
- Tickets and passes purchased are intended only for Human Service Agency clients and may not be distributed to employees of the Human Service Agency
- Tickets and passes must be used prior to the date imprinted on the front
- Ticket and pass sales are final. No exchanges or returns are permitted.
With my signature below, I certify that my organization qualifies as a Human Services Agency based on the established criteria marked above. I further acknowledge that Pierce Transit may, in its sole discretion, revoke certification if my organization has: made any material misrepresentation in this certification; violated any of the rules for use of tickets or passes as set forth above; or no longer meets the qualifications for Human Service Agency use of tickets or passes or for discounted tickets or passes.

After signing, please click green Submit button below Printed Name.
Date*

MonthDayYear
Date
Printed Name*
Questions?

Please contact ridesupport@piercetransit.org OR (253) 444 - 2526
Should be Empty:

HUMAN SERVICE AGENCY Certification Application

Questions?