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Senior & Disabled Veteran Discount

  1. For which discount are you applying?
  2. This certificate must be signed by account holder
  3. By checking this box I swear or affirm that the foregoing statements are true and correct, to the best of my knowledge and belief, and hereby grant the Authority the permission to verify my statement. Any false statements on this application may be considered as sufficient cause for rejection of this application, withdrawal of discount, back billing or other appropriate action.
  4. By checking this box I certify that I am an American Veteran who is totally and permanently 100% disabled as determined by the Veterans Administration.
  5. Leave This Blank:

  6. This field is not part of the form submission.