Accord Card Change of Circumstances Form - Change of Circumstances

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Accord Card Change of Circumstances Form - Change of Circumstances Powered By Docstoc
					                                                                                                              COC Form

Change of Circumstances

National Entitlement Card /                                    card
                                                                                                           February 2006 Issue 01
Use this form to tell us if:    you are moving home (complete parts 1, 2, 3, and 6)
                           or   your concessionary travel entitlement has changed (complete parts 1, 5, and 6)
                           or   you have changed your name (complete parts 1, 4 and 6)

Part 1 Your Details
First Name                                                      Surname

Date of Birth                          Accord Card No. 6 3 3 5           6 0 0 0

Part 2 Other Accord cardholders in the household who are also moving home
First Name                                  Surname                                               Date of Birth

Part 3 Address Details
Your old address                                             Your new address

                           Postcode                                                    Postcode

Telephone Number                                             Telephone Number

                     When did you, or do you, move to your new address?         Date
            Is your new address still within the Aberdeen City boundaries?       Yes           No          Not sure

Part 4 Change of Name and / or Title
If you are completing this form because your name and/or title has changed, please complete this section
What is your new title?         Mr       Mrs          Miss         Ms         Other

Your Old Name                                                Your New Name

Part 5 If your reason for being eligible for Free Bus Travel has changed
If the reason for your entitlement to free bus travel has changed, complete this section
Tick the reason for which you are now eligible for Scotland-wide free bus travel.                 FOR OFFICE USE
        60 or Over                                Visually Impaired                             Eligibility Proof Checked

        Disabled                                  Visually Impaired Plus Companion
        Disabled Plus Companion                   Other:

Part 6 Declaration
I declare to the best of my knowledge the information given on this form is true and complete.

Signature                                                                       Date
Please note: The information provided will only be used in accordance with the Data Protection Act 1998.

Once completed you can hand this form in at The Point, the Bucksburn or Peterculter area office, or you can
post it to the Accord Scheme, Unit 25 Frederick St. Business Centre, Aberdeen, AB24 5HY. If you completed
Part 5 of this form, you must go to The Point or either of the area offices to get your proof of eligibility checked.

This document should not be emailed as an original signature is required.              Accord Helpline 0845 345 2789