Conc. Ref:
Concessionary Travel printable application form
Please read the Concessionary Travel Information page carefully before completing and sending your application. Who is eligible? You must be a permanent resident in the Borough of Telford & Wrekin and must fall into one of the following categories: Please tick all below that apply to you: ☐ Aged 60 and over ☐ Registered blind or partially sighted ☐ Registered profoundly or severely deaf and/or without speech ☐ Someone who does not have arms or has long term loss of the use of both arms ☐ Someone who has a disability or injury which has substantial and long-term adverse effect on their ability to walk ☐ Someone who has a learning disability, that is, a state of arrested or incomplete development of mind, which includes significant impairment of intelligence and social functioning ☐ In receipt of a letter from the Department of Transport withdrawing or refusing a driving licence on medical grounds ☐ In possession of a disabled persons parking badge (Blue Badge) Receive one of the following benefits: ☐ Attendance Allowance ☐ Disability Living Allowance with Mobility component at higher rate ☐ Industrial Injuries Disability Benefit or Reduced Earnings Allowance ☐ War Disability Pension for 80% or more disability Application Form Title __________
Surname ___________________________________________
First Name (s) _____________________________ Date of Birth ___________________ Address _______________________________________________________________ _______________________________________________________________________ Postcode _________________ Telephone ____________________________________ Please tick one option that you wish to receive. Please note that by choosing an alternative option You will give up your right to choose the English Concessionary Travel Pass for a period of 12 months. ☐ ☐ ☐ ☐ English Concessionary Travel Pass Senior Persons Rail Card Travel Tokens Disabled Persons Rail Card No Cost £8 For those aged 60+ (Send no payment with this application) No Cost (Available to disabled or mobility impaired applicants only) £8 (Enclose a cheque or Postal Order payable to Telford & Wrekin Council with your application)
Please sign and date below/overleaf:
16/06/2008 gj
Notice under the Data Protection Act 1998 The Council processes data in accordance with the principles of good information handling contained in the Data Protection Act 1998. We will not sell this information to any other persons or organisations, however, the data collected may be used to provide you with information about the services offered by the Council. If you do not wish the Council to use your data in this way please tick the box [ ]. Telford & Wrekin Council is under a duty to protect the public funds it administers, and to this end may use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administrating public funds for these purposes. For further information, www.telford.gov.uk or contact the Group Auditor on 01952 383103 or by emailing auditservices@telford.gov.uk
Signature ______________________
Date _________________________
If you wish to register for the Dial a Ride service as an alternative to the above options, please complete and print the Dial a Ride application form and send it with your £2 cheque or postal order payment to the address below. When sending this application form send no payment except when applying for the Disabled Person’s Railcard. All applications should be sent to: Concessionary Travel Team, Travelink, Telford & Wrekin Council, Telford Bus Station, Coach Central, Telford, TF3 4BU
16/06/2008 gj