To all TD Bus Pass Clients:

Prior to GPTMS sending out a TD Bus Pass, you will need to fill out this form each month to determine if you have enough appointments to receive a bus pass. Please mail your check for $4.20 today, we cannot process your online application until we receive it.

Client's Name: 
Address: 
Date of Birth:
How many times in a typical month will you use your pass? 
What types of trips will you use your pass for?
Doctors's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
Doctors's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
Doctors's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
Doctors's Name: 
Doctor's Phone: 
Doctor's Address: 
Appointment Date: 
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. If you are using the pass for AA and/or NA you will need to send in a copy of your sign in sheet. If you need more room please use the back of this page. You may print out a Word document or Adobe PDF document and return by mail to:

GPTMS
13825 Icot Blvd #613
Clearwater, FL 33760