Bus passes and concessionary travel
Disabled Person’s Concessionary Travel Application Form
Version 8/DP - May 2013
Not an online form: this form must be printed out, completed by hand, and posted to the County Council (address at the bottom of final page).
Data Protection: The information given in this form will be recorded on a computer system subject to the provisions of the Data Protection Act 1998 and may be used for data matching purposes for the detection and prevention of fraud and retained for 12 months. The accompanying personal evidence will be destroyed as soon as your application has been processed. Telephone numbers are requested as we may need to contact you about your application or if you lose your pass and it is returned.
Part One - About You
Please tick one box only
I do not currently have any type of
concessionary travel pass
I am a current holder wanting to change concession (no charge).
Please return current passI am a current holder wanting a replacement due to a lost, damaged or stolen pass.
Note: A £10 fee will apply unless accompanied by an official crime number. In case of theft complete Part Two and then go straight to Part Seven to sign and date - no photo is required.
Crime Number (if applicable): _________________
-
Mr/Mrs/Ms etc:
-
Forenames
-
Surname
-
Date of birth
-
National Insurance number
-
Address
-
Postcode
-
Telephone:
-
Email:(optional)
Part Three – eligibility criteria
Please tick all that apply
Blind or partially sighted
Profoundly or severely deaf
Without speech
Disability or injury which has a substantial and long term effect on my ability to walk
Without arms or the long term loss of the use of both arms
Severe learning difficulty
Prevented from holding or would be refused a driving licence on medical grounds
Member/Veteran of the Armed Services seriously injured in service
Part Four – Type of concession required
Please tick one
A disabled person’s bus pass, or
A disabled person's companion bus pass, or
A disabled person’s vouchers
Part Five - evidence of eligibility
Proof of each of the following are required before your application can be processed (please only send copies and not originals).
- Name and Address - preferably a copy of an official letter within the last six months e.g gas/electric bill.
- Date of birth (only if applicant is under 10 years old).
Also if you are applying for a companion pass a health care letter is required
Plus ONE only of the following (tick or fill in as necessary):
Please tick
Hampshire County Council Adult Services Yellow Disabilities Registration Card.
Please provide the card number:__________________
Hampshire County Council Children’s Services Yellow Disabilities Registration Card.
Please provide the card number:__________________
Hampshire County Council Blue Badge.
Please provide the card number:__________________
Award letter for any Attendance Allowance
Award letter for the Higher Rate Mobility Component of Disability Living Allowance
Award letter for a War Pensioners Mobility Allowance
Award letter for guaranteed income payment for tariff levels 1- 8 under the 2005 Armed Forces Compensation Scheme
Letter from the DVLA giving notice of long-term refusal or withdrawal of driving licence on medical grounds (misuse of alcohol or drugs are not included under this scheme)
Award letter for personal independence payment (PIP) where the applicant has been awarded at least 8 points or more for the PIP "Moving Around" and "Communicating Verbally" activities
Only if applying for a companion pass:
Letter from a healthcare professional
Part Six - Colour passport photograph
Please ensure that you enclose a recent colour passport-sized photograph for use on your bus pass or on each voucher. Please clearly write your name and date of birth on the reverse of your photograph.
Part Seven – declaration
I confirm that I am a permanent resident in Hampshire and can only have one concession for my sole use to which I am entitled under the Transport Act 2000 and subsequent amendments. I understand that the concession is not transferable and that misuse may result in prosecution. I authorise Hampshire County Council to make any enquiries necessary to verify entitlement for travel concessions. The information given is correct to the best of my knowledge and belief. Applicants under the age of 16 will need a parent/guardian to sign the form.
Signed:_______________________________
Dated:________________________________
Please send your application form, photograph, and copies of evidence to:
Concessionary Travel
P O Box 696
Fareham
PO14 9PD
Telephone: 0845 045 8355
Textphone: 0845 603 5625
(Calls to 0845 numbers are free on some BT call plans but will cost between 4p (local rate) and 6p (national rate) per minute for BT customers not on a plan. Calls made using other service providers or mobiles may cost more).
Email: concessionary.fares@hants.gov.uk
twitter
facebook