To all TD Bus Pass Clients:

You will need to fill out this form and get it to GPTMS by the 15th of the month to receive a bus pass for the next month. The fax number and address for GPTMS are at the end of this form. You must be approved for a bus pass each month.
If you would like your pass mailed, please enclose a money order for $4.20. If you would like to pick up your pass at one of the 3 PSTA-operated ticket outlets (Williams Park, Grand Central Station, or Park Street Terminal), bring $4.20 in cash to one of the ticket outlets between the 1st and the 15th of the month. To verify that you are approved for a bus pass, call the Community Transportation Coordinator, GPTMS, at (727) 545-2100.

Client's Name: 
Social Security Number: 
Address: 
Date of Birth:
How many times in a typical month will you use your pass? 
Medical related (appointments, pharmacy, mental health clinics, support groups) 
Grocery stores 
Human services offices 
Social security offices, banks, utility companies 
Employment (list employer information for verification below) 
How many times do you expect to use your bus pass for the following types of trips?
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date(s): 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date(s): 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date(s): 
Doctor's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date(s): 
Trips to attend support groups
If you are using the pass for AA, NA, and/or other support groups you will need to send in a copy of your sign in sheet with the next month's form.
Employer: 
Employer Phone: 
Supervisor Name: 
Days Worked: 
Hours Worked Daily: 
Hourly Wage: 

You will need to complete this form completely including phone numbers and dates. We verify appointments before we issue any bus passes. You may print out a Word document or Adobe PDF document and return by mail to:

GPTMS
13825 Icot Blvd #613
Clearwater, FL 33760