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Discount GoPass
®
Tap Card Registration Form
Formulario de registro para una tarjeta de Descuento GoPass
®
Tap
Anyone who currently participates in one of the following programs automatically qualifies for a Discount GoPass Tap card:
Cualquiera que participe actualmente en uno de los siguientes programas califica automáticamente para una tarjeta de descuento GoPass Tap:
Children's Health Insurance Program
Texas Medicare or Medicaid
Comprehensive Energy Assistance Program
Temporary Assistance for Needy Families
DHA Housing Solutions for North Texas
Medicare
Supplemental Nutrition Assistance Program
Housing Choice Voucher Program (Section 8)
Special Supplemental Nutrition Program for Women Infants and Children
Workflow Status
Workflow Id
ID
Status
Currently Assigned To
Created By
Modified By
Created Date
Modified Date
Rider
Qualifying Programs List
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Referral Number
Is Active
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File url:
Reference Id:
Application Id:
Request status code:
Header:
Applicant Information
TAP Card Id
Rider Id
Created By:
Modified By:
Created:
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Modified:
Submitted Date:
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Program Id Number
Has Go Pass Yellow
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* These fields are required
• Este campo es obligatorio.
* First Name
• Nombre
Middle Initial
• Inicial
* Last Name
• Apellido
* Address
• Dirección
* City
• Ciudad
* State
• Estado
* Zip Code
• Código postal
* Phone Number (numbers only, no hyphens)
• Número de teléfono (solo números, sin guiones)
Email address
• Dirección de correo electrónico
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Date of Birth
• Fecha de nacimiento
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Add Attachment
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InstanceId:
Qualifying Assistance Programs
In which of these qualifying assistance programs do you currently participate, and have a participant card or other proof of participation?
¿En cuál de estos programas de asistencia calificados participa actualmente y tiene una tarjeta de participante u otra prueba de participación?
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AppId:
InstanceId:
Enter your Program ID number
Ingrese su número de identificación
Do you have a yellow GoPass Tap card with reduced fare through the Discount GoPass Tap Card Program?
¿Tiene una tarjeta amarilla GoPass Tap con tarifa reducida a través del Programa de tarjetas GoPass Tap con descuento?
Yes
• Si
No
• No
If Yes, please enter your GoPass Tap card number here:
En caso afirmativo, ingrese el número de su tarjeta GoPass Tap aquí:
If you have received a referral code, enter it here.
Si recibió un código de referencia, ingréselo aquí.
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Save a copy of this message for your records.
Conserve una copia de este mensaje para sus registros.
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