APPLICATION INSTRUCTIONS  
 
‐All applications MUST be filled out completely. 
‐The employment number is your 6 digit TAX number. 
‐ For Boarding stations and Destination Codes refer to PG 2 of the application. 
‐All applications MUST be hand deliver or sent through department mail to 
Uniformed Transportation Benefits located at 1 Police Plaza 10th Fl. RM 1014A 
‐ Any questions please contact the Uniformed Transportation Benefits Unit @ 
646‐610‐4291 
 
 Long Island Rail Road

MTA Police Department Official Use

Police Ride Program
Print or type only. First Name MI Last Name Shield Command Code
(Agency and station
codes are listed on
reverse side) Sex
Agency Code Tax/Employee # Pct. Rank
N Y C P D Male Female

Working Hours: (Check the box that best identifies your working hours.)
Boarding Station Code Destination Station Code
8 a.m. - 4 p.m. 12 a.m. - 8 p.m. 4 p.m. - 12 a.m. Various

Replacement request (lost of stolen) New Applicant If this is a renewal please enter If you were previously issued a LIRR Police
account number. Ride Pass, please enter account number.
Police Report No. _______________________________
P ‐  P ‐ 
Please check if you currently use the LIRR NYCPD
Agency Name___________________
for transportation to/from work

Signatures I hereby apply for an annual police pass for transportation. By signing
Annual Transportation Pass Conditions of Use
below, and If approved by the LIRR, I understand that this pass is for The conditions under which this pass is issued by the MTA Long Island Rail Road and accepted
my sole use and cannot be loaned, given to, or used by anyone other by the user are as follows:
than myself. I further agree to abide by all rules and regulations gov- 1. Police Pass is valid only for the police officer to whom it is issued and only when signed by the officer.
erning the use of this pass. The Information provided In this appllca- Pass is for officer’s exclusive and individual transportation during the period shown on its face. Pass
is not transferable and is not valid for the transportation of any persons accompanying the police officer.
tlon is true and correct.
2. The officer using the Police Pass is subject to all Laws, Rules and Regulations prescribed by the LIRR
or its customers and the public. Eligibility to participate in this program may be revoked for any violations
of the above. The LIRR also reserve the right to impose further regulations as required.
_________________________________________________ 3. Police Pass must be presented upon request to train crew personnel, MTA Police, or any LIRR official.
In addition, police officers using a Police Pass must display a Police Badge and Police Photo ID upon request.
Full signature of applicant Date Officers who do not display such will be required to pay the regular fare for transportation,
including any applicable on board charges.
I hereby certify that the above named officer is an active member of 4. If tendered for the transportation of any person other than the officer whose name and signature appears
on the face of the Police Pass, or if bears any evidence of alteration, or is mutilated. Police Pass will be
deemed forfeited and taken by the train crew personnel. Officer for whom pass was issued expressly releases
the _______________________________ and is In good standing. as the LIRR from any claim for reimbursement. Misuse of this Police Pass may result in legal prosecution.
Department’s Name 5. If Police Pass is not available for presentation to train crew personnel, fare must be paid. No refunds will
be made for such fares or lost, stolen or destroyed passes. Lost or stolen passes must be reported
to the MTA Police Department and the officer’s agency liaison, and a police report must be filed with the
jurisdiction where the lost/theft took place. Request for a replacement pass must be accompanied by a
theft/loss report and a memo requesting a replacement pass from your liaison/commanding officer.
———————————————————————–——————-- Replacement will be made on a case-by-case review and at the sole discretion of the LIRR.
Commanding Officer Rank Unit/Pct Date
6. Police Pass are at all times the sole property of the LIRR and must be surrendered by the officer upon
demand when requested to do so by train crew personnel, MTA Police, or other LIRR officials.
——————————————————————————————- 7. Police Pass has no cash value and will not be included in any refund program on account of delays or
Department Liaison, Title Date interruptions in service.
8. Police Pass is not a guarantee of transportation nor a guarantee of a seat. Officer agrees to stand if
Applicants must return applications to their Department Liaison. seats are unavailable for revenue customers due to overcrowding conditions.
Applications will NOT be accepted for processing unless your 9. In consideration for the issuance of a Police Pass, the officer agrees to release, defend, indemnify, and
hold harmless LIRR, the Metropolitan Transportation Authority, and their respective employees, officers,
Department Liaison has endorsed them. and agents from any liability for injury (including death) to the holder or damage to the property of the
holder arising from or in connection with transportation on the LIRR.
Department Liaison: Application must be complete and signed by 10. Officer will assist train crew personnel or other LIRR officials in an official capacity upon request.
You or the alternate. Please note all information is pertinent and any 11. Police Pass is not valid for excursions, admission to parlor cars, or other premium service.
missing information or signatures could delay the application process.
MTA FORM95-9/03 Front
 MTA Police Department
Police Ride Program
Station Codes  

Agency Codes

Rank
Abbreviations

MTA FORM95-9/03 Back