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					  Multi Purpose Taxi Program (MPTP)
  Department of Infrastructure (DOI)   Victorian Taxi Directorate (VTD)

  Membership Application Form

              PART A:       APPLICANT’S DETAILS
                            Part A asks for information about the person applying for the
                            program.



              PART B:       DOCTOR’S OR MEDICAL PRACTIONER’S ASSESSMENT
                            Part B needs to be filled out by the applicant’s usual doctor or
                            medical practioner, or optometrist/ophthalmologist if the disability is
                            vision related. The Victorian Taxi Directorate may ask the applicant
                            to see more doctors or medical practitoners for one or more
                            medical examinations. The applicant would have to pay for this him
                            or herself.


              PART C:       MEANS TESTING OR FINANCIAL ASSESSMENT
                            Part C asks for financial information about the applicant.

                            If necessary, please check that the required financial documentation
                            has been submitted in order to avoid unnecessary delay.



              PART D:       CONFIRMATION AND CONSENT
                            Part D is to be filled out by the applicant, his or her witness, or his
                            or her Authorised Representative. Part D on page 14 explains what
                            Authorised Representative means.



              PART E:       ATTACHMENT CHECKLIST
                            Part E is a list of things you need to send to the Victorian Taxi
                            Directorate with this Application Form.




PLEASE KEEP
THE APPLICANT
INFORMATION
SHEET THAT CAME
WITH THIS FORM.
YOU MAY NEED                Please contact the Victorian Taxi Directorate if the
TO READ IT AGAIN            ‘Protecting Your Privacy’ statement is not included in
LATER.                      this application.
Terms and Conditions of Multi Purpose Taxi Program (MPTP) Membership


             1.    The MPTP membership card can only be used by the person
                   whose details are printed on the card.

             2.    The MPTP membership card can only be used for travel in
                   taxi-cabs that have a licence to operate in Victoria, or with
                   interstate vouchers from the Victorian Taxi Directorate in
                   interstate taxi-cabs.

             3.    The MPTP member must be travelling in the taxi to receive the
                   subsidy for that trip. Carers, companions or family members
                   may travel in the taxi with the MPTP member.

             4.    Only one subsidy applies to any single trip.

             5.    The MPTP membership card is not transferable and must not
                   be used by anyone other than the member whose details
                   appear on the card.

             6.    The MPTP membership card cannot be used to send parcels
                   or packages in a taxi-cab.

             7.    Other than during a taxi trip, the MPTP member or carer must
                   keep the card in their possession at all times.

             8.    MPTP membership does not guarantee that appropriate taxi
                   transport will be available on request.

             9.    The MPTP membership card cannot be used with any other
                   transport concessions or subsidies. If a trip or part of a trip is
                   covered by insurance, for example, by the Transport Accident
                   Commission (TAC), or paid for by any State or Commonwealth
                   Department or Agency, the MPTP card cannot be used.

            10.    MPTP membership will be cancelled if the member’s
                   circumstances change and he or she stops being eligible.

            11.    The MPTP member who has been given an exemption from
                   eligibility or the annual subsidy cap may have that exemption
                   withdrawn, cancelled or amended.

            12.    The MPTP member must report inappropriate or suspicious
                   use of a MPTP membership card to the VTD as soon as
                   possible.

            13.    The MPTP member must report the loss or theft of a MPTP
                   membership card to the VTD as soon as possible.

            14.    MPTP membership may be cancelled if a member does not
                   comply with these terms and conditions. The Victorian Taxi
                   Directorate may also take legal action.

            15.    It is understood that the applicant or the Authorised
                   Representative understands and accepts the terms and
                   conditions of MPTP membership when they sign an
                   application form.
PART A: APPLICANT’S DETAILS
To be completed by the Applicant or the Applicant’s Authorised Representative
(as defined in Part D – Page 14)

                                                                                OFFICE USE ONLY
                                                                                Application Number




                                  Please use BLOCK letters when completing the form


A1. Applicant’s Details
                               s Mr            s Mrs             s Miss       s Ms
                               Surname or Family name
                               First or given name

                               Date of birth         /       /            s Male s Female
                               Residential address
                                                                             Postcode
                               Postal address

                                                                             Postcode

                               Telephone – home          (   )
                               Telephone – business (        )

                               Mobile


A2. Is the applicant a
    permanent resident
                               s Yes            s No
    of Victoria?
A3. Has the applicant
    previously applied
                               s Yes            s No
    for membership in
    this program?
A4. Does the applicant
    hold a commercial
                               s Yes            s No
    Driver’s Certificate (to
    drive a taxi, bus etc)?
A5. Does the applicant
    permanently need the
                               s Yes            s No
    use of a wheelchair?
A6. Does the applicant
    use a mobility aid other
                               s Yes         s No If yes, please indicate which mobility aid(s):
    than a wheelchair?         s Walking stick s Walking frame s Four point stick
                               s White cane         s Guide dog       s Scooter
                               s Other (please specify)
A7. Please tick which
    type(s) of transport
                               s Driver of private car          s Passenger in private car
    the applicant
    presently uses:
                               s Train          s Tram          s Bus        s Taxi         s None
PART A: APPLICANT                               CONT’D
To be completed by the Applicant or the Applicant’s Authorised Representative


A8. Does the applicant’s
    disability permanently stop
                                            s Yes           s No       If yes, please describe how:
    him or her from safely
    and independently
    accessing public transport?




A9. Please tick the main                    s employment; or
    purposes that the applicant
    will use taxi travel for.               s education / training / day program; or
    (This information will not affect the   s medical; or
    applicant’s eligibility for the         s volunteering; or
    program, but only to find out
    typically how taxi travel will be
                                            s social / recreation; or
    used.)                                  s other (please specify)   –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––




A10.Is the applicant able to sign           s   Yes         s     No
    documents?




                                            OFFICE USE ONLY
                                             Approved by – Initials                                                   Date                  /           /

                                             Application Number

                                             Disabilities/Mobility Aid D1              D2                  D3                  MA

                                             Checked by – Initials                                                     Date                 /           /

                                            EDA   s        TPI   s
                                              Comments
PART B:           DOCTOR’S OR MEDICAL PRACTITIONER’S ASSESSMENT
Assessment to be completed by the Applicant’s regular Medical Practitioner
Optometrists/Ophthalmologists may complete for vision related disabilities


 IMPORTANT
 The MPTP assists Victorians who are prevented from independently using public transport
 because of a severe and permanent disability.
 People are only eligible for the MPTP if their disability is:
 • Permanent: for the term of a person’s life and not expected to improve
 • Severe; of a type that severely limits mobility and safe and independent travel on public
   transport; not mild or moderate.

 Factors which cannot be taken into consideration in determining eligibility include:
 • a person’s age.
 • lack of available transport.
 • eligibility to hold a driver licence.

 Please ensure that all sections are complete to prevent the application being returned to you
 and delaying the processing of the application. Your complete answers to questions are critical
 in the assessment of the applicant’s eligibility.


                     Please use BLOCK letters when completing the form
Diagnosis
B1. What is the diagnosis
                             a) primary
    of the applicant’s
                             b) secondary
    disability?
                             c) other

                             If a) b) or c) is a visual impairment, please provide acuity reading with
                             best corrected vision.

                             left eye         6/         right eye        6/

                             and /or visual field
B2. Grade the severity
                            a) primary
    of each disability
    (mild/moderate/severe): b) secondary
                            c) other


B3. Grade the resultant
                            a) primary
    activity limitation
    (mild/moderate/severe): b) secondary
                            c) other


B4. Is the disability(s)            primary                  secondary                     other
    permanent?
                             a)   s Yes s No            b)   s Yes s No             c)   s Yes s No
B5. Please specify how
                             a) primary                 Years                       Months
    long the disability(s)
    has existed.             b) secondary               Years                       Months
                             c) other                   Years                       Months
PART B:         DOCTOR’S OR MEDICAL PRACTITIONER’S ASSESSMENT
Assessment to be completed by the Applicant’s regular Medical Practitioner
Optometrists/Ophthalmologists may complete for vision related disabilities

Mobility
B6. Does the applicant
    permanently (being for
                                   s Yes          s No
    the term of their life and
    not expected to improve)
     require the use of a
     wheelchair for mobility
     outside the home?


B7. How far can the
    applicant walk without
                                   s 0-10 m s 10-50 m              s 50-100 m   s 100-200 m
    stopping?                      s more than 200 m
B8. Can the applicant
    climb 3 steps up
                                   s Yes          s No
    and 3 steps down?

B9. Do you consider that
    the applicant is able to
                                   s Yes          s No
    travel safely on public
    transport without severe
    pain or discomfort?

B10. Is the applicant able
     to travel independently
                                   s Yes          s No
     on public transport?

B11. Is the disability(s)
                                   a) primary             s Yes          s No
     likely to improve with
     medical treatment, such
                                   b) secondary           s Yes          s No
     as further surgery, to the    c) other               s Yes          s No
     extent that the applicant
     will be able to safely and
     independently travel on
     public transport?

B12. Impact of disability.
     Please describe in full the
     functional impact of the
     applicant’s disability in
     using public transport.
PART B:         DOCTOR’S OR MEDICAL PRACTITIONER’S ASSESSMENT
Assessment to be completed by the Applicant’s regular Medical Practitioner
Optometrists/Ophthalmologists may complete for vision related disabilities

Declaration
B12. Please provide the     My signature below verifies ALL of the following:
     the length of time    • I have seen the applicant in a professional capacity for
     that you have treated                   years and                       months
     the applicant.
                            • The information I have supplied in this application is true
                              and correct.
                            • I am not the applicant or an immediate family member of
                              the applicant.
                            • I acknowledge that this application may be referred to a
                              health professional / MPTP Panel for further assessment
                              and review.
                            • I agree to offer all reasonable assistance and records to
                              assist the Victorian Taxi Directorate and the MPTP Panel
                              or its nominated representatives to determine the applicant’s
                              eligibility.


B13. Please complete        Name
     your personal
                            Employer / business name
     details and verify
     declaration.           Address

                                                                             Postcode

                            Telephone – business

                             Signature
                             ✍
                            Date         /      /

B14. Please indicate in     s GP
     what capacity you
     have made your         s Specialist
     assessment.
                            s Psychologist/Psychiatrist
                            s Optometrist/Ophthalmologist
                            Medical Practitioner’s Board of Victoria Registration Number



                              Professional stamp (if available):
PART C:         MEANS TESTING OR FINANCIAL ASSESSMENT
To be completed by the Applicant or the Applicant’s Authorised Representative


 If the Applicant’s doctor or medical practioner answer ‘YES’ to question
 B6 on page 6, ‘Does the Applicant permanently require the use of a
 wheelchair for mobility outside the home?’, then go to PART D on
 page 13. You do not need to fill in Part C.
 If the applicant’s doctor or medical practioner answered ‘No’, go to
 Question C1 below. You do need to fill in Part C.

C1. Is the applicant:            Note: Dependent means that a child or student is either:-
    a dependent child aged       • 2 to 15 years old, or
    under 21 years old           • 16 to 24 years old and either has an annual income less than
              or                   $8,614 or is receiving a Prescribed Education Scheme payment
    A qualifying dependent         such as ABSTUDY; or
    full-time student aged       • not receiving a pension, a Labour Market Program payment of
    21 to 24 years?                under 21 years old benefit such as Youth Allowance.



                                 s   No, go to Question C2
                                 s   Yes, go to Question C9 on Page 10



C2. Does the applicant have a
                                 s   No, go to Question C4 on Page 9
     current Department of
                                 s   Yes, complete the following details:
     Veterans’ Affairs issued
     Pensioner Concession
     Card or gold Repatriation
     Health Card?                Customer Ref Number


                                 Expiry date: Month                         Year




C3. Tick if the applicant is a
                                 s Extreme Disablement Adjustment (EDA)
     veteran who qualifies for
                                 s Totally and Permanently Incapacitated (TPI)
     one of these entitlements

                                   Please attach a photocopy of the applicant’s card to this form.
                                   Do not attach the card.

                                 GO TO PART D - ON PAGE 13
PART C:          MEANS TESTING OR FINANCIAL ASSESSMENT                                 CONT’D
To be completed by the Applicant or the Applicant’s Authorised Representative


C4. Does the applicant
                                s No, go to Question C5
    have one of these
    Pensioner Concession
                                s Yes, please indicate which concession card the applicant holds and
                                    complete the details below:
    Card or Health Care
    Card (HCC) issued           s Pensioner Concession Card
    by Centrelink?              s Newstart Allowance HCC (NS)
                                s Sickness Allowance HCC (SA)
                                s Special Benefit HCC (SpB)
                                s Widow Allowance HCC (WA)
                                s Youth Allowance HCC (YA)
                                s Low Income HCC (LI)
                                s Family Tax Benefit A HCC (FA)
                                s Partnered Parenting Payment HCC (PP)
                                s Partner Allowance HCC (PA)
                                s Exceptional Circumstances/Drought Relief HCC (DR)
                                Customer Ref Number

                                 Expiry date: Month                         Year

                                    Please attach a photocopy of the applicant’s card to this form.
                                    Do not attach the card.

                                GO TO PART D - ON PAGE 13

C5. What is the
                                s Single
    applicant’s marital
    status?
                                s Widowed
                                s Divorced
                                s Separated
                                s Married or in a de facto relationship and currently living together
                                s Partnered but unable to live together
                                s Other
C6. Does the applicant
    have any dependant
                                s Yes s No
    children as defined
    in Part C1?
    If yes, what is the total
    number of children
    dependent children
    aged under 21 and
    qualifying dependent
    full-time students
    aged 21-24 years in
    the family?                 s 1 s 2 s 3 s 4 s other, please specify
PART C:            MEANS TESTING OR FINANCIAL ASSESSMENT                                      CONT’D
To be completed by the Applicant or the Applicant’s Authorised Representative



C7. Is the applicant currently          s Yes s No
    employed?

C8. What is the total taxable
                                        $
    income of the applicant’s
    family?*
                                          The family’s most recent tax return/s and tax assessment/s.
     * Family includes all parents or     If the family owns a property, a recent rates notice.
     guardians, but does not include
                                            If the family rents a property, a recent rental statement.
     other adults living with the
     applicant.                             If the family has a housing loan, a recent statement
                                            showing the repayment amounts.
     Please attach
                                            If the family is employed, their last eight payslips or a letter from
     photocopies of the
                                            their employer/s stating their gross income.
     following documents:
                                            Proof of any family income such as superannuation, pension,
                                            WorkCover payments or investments such as properties or shares.
                                            Proof of any family exceptional circumstances or costs to do with
                                            the applicant’s disability, for example, exceptional travel
                                            requirements, medical bills, medication costs, medical treatment
                                            or unavoidable disability related expenses.
                                        GO TO PART D - ON PAGE 13


C9. Parent/Guardian                     Surname / Family name
     Means Test/                        First or given name
     Financial
     Assessment                         s Mr         s Mrs         s Miss        s Ms
     Where the applicant is a           Relationship to applicant
     dependent child, the
     income of the applicant’s          s male s female
     family is assessed. The            Telephone – business
     applicant’s parent/s or
     guardian/s must                    Telephone – home
     complete the following:            Mobile

                                        Number of adults in family (includes all parents or guardians, but
                                        does not include other adults living with the applicant).

                                        s 1 s 2 s 3 s 4 s other, please specify
PART C:        MEANS TESTING OR FINANCIAL ASSESSMENT                                CONT’D
To be completed by the Applicant’s Parent/s or Guardian/s


C10. What is the marital
     status of the
                             s Single
     applicant’s             s Widowed
     parent/s or
     guardian/s?             s Divorced
                             s Separated
                             s Married or in a de facto relationship and currently living together
                             s Partnered but unable to live together
                             s Other
C11. What is the total
     number of parent/s or
     guardian/’s dependent
     children aged under
     21 and qualifying
     dependent full-time
     students aged 21-24
     years in the family?    s 1 s 2 s 3 s 4 s other, please specify
C12. Does either of the
     applicant’s parent/s
                             s No, go to Question C13 on Page 12
     or guardian/s have      s Yes, please indicate which concession card is held and complete
     one of these               the details below.
     Pensioner
     Concession Card or
     Health Care Cards
                             s Pensioner Concession Card
     with the codes          s Newstart Allowance HCC (NS)
     listed below issued
     by Centrelink?
                             s Sickness Allowance HCC (SA)
                             s Special Benefit HCC (SpB)
                             s Widow Allowance HCC (WA)
                             s Youth Allowance HCC (YA)
                             s Low Income HCC (LI)
                             s Family Tax Benefit A HCC (FA)
                             s Partnered Parenting Payment HCC (PP)
                             s Partner Allowance HCC (PA)
                             s Exceptional Circumstances/Drought Relief HCC (DR)
                             Customer Ref Number

                             Expiry date: Month                      Year

                                Please attach a photocopy of the applicant’s parent/s’ or
                                guardian/s’ card/s to this form. Do not attach the card.


                             GO TO PART C14 - ON PAGE 12
PART C:           MEANS TESTING OR FINANCIAL ASSESSMENT                                        CONT’D
To be completed by the Applicant or the Applicant’s Authorised Representative


C13. What is the total taxable
                                          $
      income of the applicant’s
     family?*

     *A family includes all parents or        The family’s most recent tax return/s and tax assessment/s.
     guardians, but does not include          If the family owns a property, a recent rates notice.
     other adults living with the
     applicant.                               If the family rents a property, a recent rental statement.

     Please attach the                        If the family has a housing loan, a recent statement showing
     following documents.                     the repayment amounts.
                                              If the family is employed, their last eight payslips or a letter
                                              from their employer/s stating their gross income.
                                              Proof of any family income such as superannuation, pension,
                                              WorkCover payments or investments such as properties or shares.
                                              Proof of any family exceptional circumstances or costs to do with
                                              the applicant’s disability, for example, exceptional travel
                                              requirements, medical bills, medication costs, medical treatment
                                              or unavoidable disability related expenses.


C14. Parent or Guardian                  I authorise the Victorian Taxi Directorate to make contact with any
     Authorisation                       people or organisations to check any of the information provided
                                         in Part C of this form. This includes contacting Commonwealth
                                         Government department’s or agencies about any Commonwealth
                                         concessions or benefits my family receives.

                                         Signature:
                                         ✍

                                         Date:            /          /

                                         (If this authorisation is not provided or is revoked, the applicant
                                         may not be eligible for membership of the Multi Purpose Taxi
                                         Program)

                                         GO TO PART D - ON PAGE 13
PART D: CONFIRMATION AND CONSENT
To be completed by the Applicant or the Applicant’s Authorised Representative


D1.   Is the applicant       s   Yes, complete D1             s   No, go to D2
      capable of
      completing the         I, (insert your name)
      form and               • certify that the information about me in parts A & C are correct.
      consenting to the
      VTD checking           • authorise the Victorian Taxi Directorate (VTD) to check any of the
      details as required?     information provided in this form. This includes contacting the
                               Commonwealth Government Departments or Agencies about any
                               Commonwealth concessions or benefits I receive.
                             • note that the above authorisation will be treated as ongoing but can be
                               revoked. I understand that, if my authorisation is revoked, I may no
                               longer be eligible for the Multi Purpose Taxi Program (MPTP).
                             • authorise and consent to my doctor or medical practitioner providing
                               the VTD with health information about me so that it can assess my
                               application.
                             • authorise and consent to my health information being disclosed by the
                               VTD to an independent health professional or MPTP Panel if the
                               VTD considers it necessary. If my application is referred to such a
                               professional or Panel, I authorise and consent to them providing
                               health information about me to the VTD.
                             • agree to abide by the terms and conditions of the MPTP membership
                               on page 2 of this form. I also acknowledge that misuse of the MPTP
                               membership card will lead to cancellation of my membership and/or
                               legal action.
                             • acknowledge that my signature below indicates that I agree to the
                               statements made above.
                             Signature
                             ✍
                             Date           /            /

                             GO TO PART E - ON PAGE 15

D2.   Is the applicant
      capable of
                             s   Yes, complete D2             s   No, go to D3
      confirming and         I certify that the applicant has either read this application, including the
      consenting to the      Terms and Conditions of Multi Purpose Taxi Program membership on
      VTD checking           page 2 of this form, or that the applicant has had them read to him or
      details as required    her, and agrees to the statements in point D1.
      but unable to sign     Signature of witness to applicant’s consent:
      the form?
                             ✍
                             Date            /            /

                             Name

                             Address

                                                                    Postcode

                             Contact Phone No.

                              GO TO PART E - ON PAGE 15
PART D: CONFIRMATION AND CONSENT
To be completed by the Applicant or the Applicant’s Authorised Representative


D3.   Confirmation and          An applicant is unable to consent on his or her own behalf if he or
      Consent of Authorised     she is incapable of understanding the general nature and effect of
      Representative            consenting, or is unable to communicate his or her consent, even
                                when given reasonable assistance by someone else. This may
      To be completed by the    because of age, injury, disease, senility, illness, disability or physical
      applicant’s Authorised    impairment.
      Representative if the
      applicant is incapable
      of consenting on his or
      her own behalf.

D4.   The authorised            Please indicate on what basis you are an Authorised Representative.
      representative must       An Authorised Representative is defined as:
      tick the box to which
      category they belong      s      A guardian, administrator or person responsible within the
                                       meaning of the Guardianship and Administration Act 1986.
      and provide the
      information requested
      below.                    s      An attorney for the applicant under an enduring power of
                                       attorney.

                                s      An agent for the applicant within the meaning of the Medical
                                       Treatment Act 1988.

                                s      A parent or guardian of the applicant, if the applicant is a child.

                                s      A person otherwise empowered under law to perform any
                                       functions or duties or exercise powers as an agent of or in
                                       the best interests of the applicant.

                                On the applicant’s behalf, I agree to statements as specified in Part D1.
                                Signature:
                                ✍
                                Name

                                Address

                                                                          Postcode

                                Telephone                                 Date         /         /


                                GO TO PART E - ON PAGE 15
PART E: CHECKLIST


                            Please check that relevant photocopies of the following are
                            attached to this form, if relevant:


                               s the applicant’s current Pensioner Concession Card or gold
                                   Repatriation Health Card issued by the Department of Veteran’s Affairs.

                               s the applicant’s family’s current Pensioner Concession Card or
                                   gold Repatriation Health Card issued by the Department of
                                   Veterans’ Affairs.

                               s the applicant’s current Pensioner Concession Card or Health Care
                                   Card (HCC) issued by Centrelink.

                               s the applicant’s family’s current Pensioner Concession Card or
                                   Health Care Card (HCC) issued by Centrelink.

                               s financial information such as:
                                           •   most recent tax return/s
                                           •   most recent tax assessment/s
                                           •   recent rates notice
                                           •   recent rental statement
                                           •   recent home loan statement
                                           •   last eight payslips
                                           •   letter from employer/s stating gross income
                                           •   proof of any other income
                                           •   unavoidable disability related expenses.
                                           •   proof of any exceptional circumstances or costs.



Please post the             Victorian Taxi Directorate
application and             Multi Purpose Taxi Program
attachments to:             PO Box 666
                            North Melbourne Vic 3051

Contacts for further
information
Melbourne Metropolitan
Telephone callers           (03) 9320 4360
Telephone country callers   1800 638 802
Postal Address              PO Box 666
                            North Melbourne Vic 3051
Office Address              Level 6, 14-20 Blackwood Street, North Melbourne Vic 3051
Internet Address            www.taxi.vic.gov.au
Email Address               mptp.taxitow@doi.vic.gov.au

				
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Description: Multi Purpose Taxi Program (MPTP)