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Bus Transportation Request
Please Fill Out and Return To:
Senior Citizen Affairs
Town of North Hempstead
220 Plandome Road
P.O. Box 3000
Manhasset, NY 11030
You may type information into each field and then print out the completed form.
Destination:
Roosevelt Field Food Shopping
Your Name:
Your Address:
Your Phone Number:
Your Town of North Hempstead Senior Citizen I.D. Card Number:
Current Medical Condition(s):
(Example: Diabetes, High Blood Pressure, Heart Problems, Arthritis, etc.)
Do You Use a Cane or Walker?
Cane Walker
Do You Have a Vision Problem?
Yes No
Do You Have a Hearing Problem?
Yes No
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