Revised February 2024
65 Plus Application Instructions
Complete and submit the application form:
Make sure the application is complete, print clearly, and do not use pencil or highlight any
Be sure you sign your application
Attach a clear, legible photocopy of one of the following proof of age documents to the
o Passport
o Driver’s License
o Pennsylvania Photo Identification Card
Completed applications and a clear, legible copy of the accepted photo ID can be scanned and
emailed to: or a hard copy can be mailed to ACCESS
Transportation Systems, 650 Smithfield St., Suite 440, Pittsburgh, PA 15222
We cannot accept applications by fax
Applications that are incomplete or illegible will be returned
Information needed about you:
You must be aged 65 or over
If you use a wheelchair, other mobility aid, or need other special assistance (ex., I am blind)
please note this in the appropriate space on the application form
If you require written materials in an accessible format, please record that in the space
provided on the application
Emergency contact information including a cell phone number if available
When will I receive my ACCESS 65 Plus welcome packet?
You will receive your ACCESS 65 Plus welcome packet and information about how to use the
service within about two weeks from the date your application was received.
Additional Questions?
If you have questions or need assistance with any aspect of this process, please call (412) 562-
5353 or TTY 711.
Questions? Call
(412) 562-5353 or TTY 711
Office hours are Monday
Friday 8 a.m.4:30 p.m.
Find ACCESS information
online at
_ _ _ _ _ _
Revised January 2021 ACCESS Use Only
65 Plus Program Application
Please print legibly.
Name of Applicant (Last, First, Middle Initial) Date of Birth (MM/DD/YY)
Address (Apt. #) (City) (State) (Zip Code)
Telephone Number:
Home ________________________Work ______________________Cell_____________________
E-mail Address:___________________________________________________________________
Emergency Contact:
Name ____________________________Telephone __________________Relation______________
Mobility Aid: Wheelchair Service Animal Walker Scooter White Cane Other__________
Accessible Formats for future print material? Large Print Braille E-Mail Other_____ _
Signature of Applicant (Required)
I certify that the above information is true, accurate and complete.
Date Received: Date Card Issued:
Please Tape a Clear Copy of Proof of Age Below
Driver’s License, PA Photo Identification Card or Passport only
If the copy doesn’t fit, please use the reverse side.