Bill Book Proforma - DOC - DOC by rgz11453

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									                                                                                                                                            PAYMENT METHOD
                                                                         VEHICLE DETAILS
  APPLICATION FOR RESIDENT PERMIT/VOUCHERS
                      HIGH WYCOMBE                                          Registration ____________________________                             Debit Card                  (American Express and

     ONE PERMIT PER PERSON, PER VEHICLE                                     Model         ______________________________                          Credit Card               (Diner Cards not accepted)
APPLICATION DETAILS                                                         Colour        ______________________________                          Cheque/Postal Order
  Title             ________________________________                        Make          ______________________________                    Please make cheque/P.O. payable to Wycombe
  Name              ________________________________                        CO2 (g/km ________________ ______________                       District Council
                                                                                                                                            Or tick appropriate card type – please note there is a
  Surname           ________________________________
                                                                                                                                            handling fee of 1.6% on credit card transactions
  Address           ________________________________                      PERMIT DETAILS                                                    Visa debit/credit / Mastercard/ Maestro / Switch / Solo /
                    ________________________________                        One permit per person, per vehicle allowed                      Electron / other – please state ____________________
  Postcode          ____________ Tel No_____________                                                                                        Card No. _________________________________
                                                                               12 month permit                           £52
          Do you have a garage or off street parking?                                                                                       Security Code (last 3 digits on back of card) ________
                                                                               6 month permit                            £30
                              YES/NO
                                                                               3 month permit                            £30                Start Date _____ Expiry Date _____ Issue No ___
PROOF OF RESIDENCE
                                                                               Replacement permit (lost or change of vehicle)   £10         Name on Card ____________________________
  MUST BE PROVIDED
          A COPY OF CURRENT RESIDENTIAL COUNCIL                                                                                                            REFUND – NOT AVAILABLE
          TAX STATEMENT OR FRONT PAGE & Pg 9 OF
          CURRENT COUNCIL TAX BOOK                                        DAILY RESIDENTIAL VISITOR VOUCHERS
                                                                                                                                            DECLARATION
          ***   AND ***                                                   Limited to 50 vouchers, per person, per 3 month period.
  PLEASE TICK ONE ONE BELOW AND SUPPLY                                                                                                      I declare that all information completed on this form is true
                                                                                 X 10     (£10 per book)                                    and correct and I acknowledge that the permit will be
          Utility Bill (issued within the last 3 months)                                                                                    withdrawn if the conditions of issue are contravened.
          Rent Agreement/Mortgage Statement (no older than 1
                                                                                                                                            Signature_________________________________
            year)                                                         CHANGE OF VEHICLE
                                                                                                                                            Date_____________________________________
          Driving Licence (with the High Wycombe address)                 I hereby surrender my Resident Parking Permit
          Proforma Letter (signed by an approved referee)                                                                                   DATA PROTECTION STATEMENT
                                                                          RES\..........................                                    Wycombe District Council will process your information for the
                                                                                                                                            operation of the Civil Enforcement Area (PCNs/Permits).
PROOF OF VEHICLE OWNERSHIP                                                                                                                  Processing will include the use of cameras to record data. Your
                                                                          DEFACED PERMIT                                                    information may be dislcosed to, or requested from, the Driver
  Please tick one and supply                                                                                                                and Licensing Agency (DVLA), local authorities, law
                                                                          I enclose my defaced Parking Permit                               enforcement agencies and other organisations for the
                                                                                                                                            administration (including verification of discount entitlement)
          Vehicle Registration Document (with your name and
                                                                                                                                            and enforcement of the scheme; the prevention and detection
          residential address)                                                                                                              of crime and protection of public funds.
                                                                          REPLACEMENT DUE TO LOSS OR THEFT                                  Wycombe District Council randomly selects and monitors
          Company Letter (updated letter on headed                                                                                          vehicles to identify possible fraudulent use. Persistent failure
          notepaper, detailing full name, residential address,            I declare that my resident Parking Permit has been                to pay enforcement charges due or attempt to defraud the
          vehicle details and that you are the sole user of this          lost/stolen and I wish to apply for a duplicate. I                scheme, Wycombe District Council may record the vehicle’s
          vehicle).                                                       undertake to return the aforementioned permit if it               movements and may disclose relevant details to local
                                                                                                                                            authorities and/or law enforcement agencies, to assist in
                                                                          subsequently comes into my possession.
          Hire/Lease Agreement                                                                                                              tracing persistent evaders and those committing fraud.

          Authorised Bill of Sale                                         Reason______________________________________


Revised 23.09.2010 CR                Please return to Parking Services, Wycombe District Council, Queen Victoria Road, High Wycombe, Buckinghamshire, HP11 1BB Telephone 01494 421417

								
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