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Request or Print an Application

Fill out the requested information below. Most fields are required and are indicated with an asterisk next to the field name.

  • If you prefer the Low Income Discount Administrator send you a pre-populated application via regular mail, select the "Send me an Application" button.
  • If you prefer to print your application now, fill in the remaining fields, and mail or fax it back, select the "Print my Application" button.
  • Please note: If you provide us with an email address, we can email you our application review decision the day of the review.
* indicates required fields
 
First Name*
    Last Name*
    
   Middle Initial
   
 
Mailing Address*
    Apt No
    
 
City*
    State
    
   Zip Code*
   
 
Date of Birth (mm/dd/yyyy)*   
/ /
    Social Security Number (last 4 required)*   
    - -
 
Telephone Number   
- -
    Email Address
    
 
   ** OR **