Disabled Person�s Rail Card Application Form by TW4yGYQJ

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									                                                               OFFICE USE ONLY
                                                             DP

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Disabled Persons Railcard Application Form              DPRC10W
                                                        Valid until 1 January 2011
Please complete all sections

Title                                     Please indicate your title here
Mr
Mrs
Miss
Ms
Other

Date of Birth:

First Name:

Surname:

Home address:

Town:

Postcode:

Daytime telephone:

Email:

Buying your Railcard
You must send in the stated evidence of your disability to be able to purchase a
Disabled Persons Railcard.

I would like (please indicate):


Railcard type                                              Please indicate the
                                                           type of card you would
                                                           like here
A one year Railcard (price £18)
A three year Railcard (price £48)
Payment method                                       Please indicate the method
                                                     of payment you are using
                                                     here
Cheque (payable to “Disabled Persons Railcard”)
Postal Order
Rail Warrant
Visa
Delta
Mastercard
Electron
Solo
Maestro

Name on card:

Card number:

Valid from:
Valid to:
Issue number (if applicable):

Last three digits on security strip:

Declaration

Before signing this declaration it is important that you have understood and
agreed to the Terms & Conditions shown in this leaflet, together with the National
Rail Conditions of Carriage. Copies of the National Rail Conditions of Carriage
are available online at www.nationalrail.co.uk/nrcc. Alternatively you can contact
National Rail Enquires or the Disabled Persons Railcard office for details of
availability.

I have understood and agree to the Terms & Conditions of the Disabled Persons
Railcard. I confirm that the details I have provided are correct and that I can
provide evidence that I meet the qualifying criteria for a Disabled Persons
Railcard.

Signature:                                                    Date:
You                  Please send in one of the following          Please indicate
                     with your application (photo-copies          which criteria you
                     and printed scans are acceptable)            are applying
                                                                  under here
Are registered as    Social Services official stamp in the
having a visual      space below this table
impairment           A copy of your Certificate of Visual
                     Impairment (CVI)
                     A copy of your BD8 certificate for being
                     registered blind or partially-sighted
Are registered as    Social Services official stamp in the
deaf or use a        space below this table
hearing aid          NHS hearing-aid battery book
Have epilepsy and    Either your customer copy or a
either:              photocopy of your prescription for
have repeated        epilepsy medication that contains drugs
attacks even         in line with National Society for Epilepsy
though you           guidelines.
receive drug
treatment or
are currently
prohibited from
driving because of
your epilepsy        A copy of your letter from the DVLA
                     telling you that you are unable to drive
Receive              A copy of your award letter
Attendance
Allowance
Receive Disability   A copy of your award letter
Living Allowance
at either:
the higher rate or
lower rate for
getting around
(mobility) for one
year or longer or
the higher or
middle rate for
help with personal
care
Receive Severe       A copy of your award letter
Disablement
Allowance
Receive War          A copy of your award letter
Pensioner's
Mobility
Supplement
Receive War or       A copy of your award letter
Service
Disablement
Pension for 80%
or more disability
Receive Long         A copy of your Certificate of Taxable
Term Incapacity      Incapacity Benefit & Income Tax
Benefit
                     Written confirmation from jobcentreplus
                     or the DWP that you receive Long Term
                     Incapacity Benefit
Are buying or        A copy of the leasing or hire-purchase
leasing a vehicle    agreement
through the
mobility scheme

Social Services Stamp here:


Please indicate if you would like the following:

A Braille sticker on your Railcard:

A Railcard Wallet:

Renewal notices
We will send you a reminder to renew your Railcard before it runs out. Please tick
your preferred way of receiving this reminder:
      Email
      Letter
      Large print
      Phone call
      Audio CD
      Braille

Research
We periodically contact customers to find out how we can improve our service. If
you do NOT want to take part in these surveys please tick here:

Offers and Useful Information
If you would like us to allow companies to send you details of products and
information that you might be interested in. If you do NOT want to receive this
information please indicate here:
Please send this completed form, together with the evidence, to:

Rail Travel Made Easy
PO Box 11631
Laurencekirk
AB30 9AA

								
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