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
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email
example@example.com
1. Is the above listed organization a federal, state or local government agency or other organization that provides human services to its clients?
2. Please check the primary purpose(s) of services you provide to members of the public (check all that apply):
Other primary purpose, please describe here:
3. Is your organization tax-exempt under the IRS subsection 501(c)3?
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 hsa@piercetransit.org or 253-581-8000
Should be Empty:

HUMAN SERVICE AGENCY Certification Application

Questions?