Copeland Borough Council

Copeland Borough Council

Concessionary Travel Registration Form

Applicant details (please print in BLOCK CAPITALS in black ink):

Title

First names

Surname

Date of Birth:

Gender:

Male

Female

Address:

Post Code:

Telephone number:

Qualification details (TICK ONE): Note: You should read the details of the scheme on the reverse of this form to ensure that you are eligible for travel concessions.

Age 60+		Those without speech
Registered Blind		Those with a mental disability
Partially Sighted		Persons without the use of both arms
Those disabled with permanent and substantial impaired ability to walk		Persons refused a driving licence on medical grounds
Profoundly or severely deaf

I wish to apply for:

Bus Pass

(complete NowCard form)

Vouchers

(complete this form only)

Bus Pass for a Companion (see note 8 overleaf)

Vouchers for a Companion

(see note 9 overleaf)

Senior Citizens Rail Card

(also complete Railcard form)

Please note: you can ONLY apply for, or hold, ONE form of concession. If you already have a bus pass and now wish to apply for vouchers or a railcard, you must return your bus pass or you will not be able to receive another concession until the following year. Tick this box if you already have a bus pass. *

Copeland Borough Council may share this information across its departments if it will help to improve the service you receive. However, the Council will not pass this information onto any third party unless we have your consent or we have a legal obligation to do so under the Statutory Powers. Please tick this box if you do not wish for this information to be shared. *

Evidence required:

Qualification	Evidence required - one of the following:
Age 60+	Birth certificate / passport / driving licence/ prescription / over 75 TV licence/ old Retirement Pension Book/ or another formal document showing date of birth Certificate from Benefit Agency (or Pink Pension Card) Letter from Pensions Agency showing receipt of state retirement pension
Registered Blind	Registration certificate
Partially Sighted
Those disabled with permanent and substantial impaired ability to walk		Benefit order books or Annual Award/uprating notices from Benefits Agency for : - - War pensioners mobility supplement or the - *HIGHER RATE of* MOBILITY component of Disability Living Allowance -Registered Blue Badge Holder Doctor's certificate stating which category of disablement applies to the applicant.
Profoundly or severely deaf
Those without speech
Those suffering from a mental disability
Persons without the use of both arms
Persons refused a driving licence on medical grounds.

Terms of the scheme

If you already have a bus pass and wish to retain this as your concession, you do not need to fill out this form.
You will need to provide evidence with all applications to be able to receive your concessions unless you quality as age 60+ and have previously registered for the scheme.
Forms must be received with the evidence at the address overleaf by post or in person at an area office to qualify.
All concessions will be posted direct to your home address. If required, you must return your bus pass before this date, or the concession will not be posted out.
Receipt of Railcard excludes the claimant from receiving any other travel concession for 12 months following issue.
Receipt of Vouchers excludes the claimant from receiving any other travel concession until 1^st April following issue.
BUS PASS - applicants wishing to apply for a replacement should contact the Council.
BUS PASS -these are only available for companions of those so severely disabled that require assistance to travel by public transport.
Vouchers are only available for companions of those so severely disabled that they require assistance to travel by public transport.

Office Use Only:

Rcvd Post * Received at Office * Old Bus Pass Returned * Y * N * N/A Evidence Rcvd * Y * N Type (i.e. Passport etc) ___________________

Date Evidence Checked / /

Date Evidence Returned / / CBC Signature_________________________ 0x08 graphic

New Bus Pass App to NowCard *

Received Date Stamp

I have read the terms of the scheme and confirm I meet the qualification requirements

Signature of Applicant: ___________________________ Date: _________________

Proof of eligibility must be enclosed with this registration form.

After completion, return this form to: Travel Concession (Customer Services Department), Copeland Borough Council, Millom Council Centre, St Georges Road, Millom, Cumbria, LA18 4DD.