Diamond Travelcard application form
for disabled applicants



Council documents can be made available in large print, audio, easy read and other formats. 
Help is also available for people who need council information in languages other than English.

For more information contact the Diamond Travelcard Office on 01934 426 426 or 
email: diamond.travelcard@n-somerset.gov.uk.



You can return your completed form by post to: 
North Somerset Council, Diamond Travelcard Office, Somerset House, Oxford Street, Weston-super-Mare, BS23 1TG. 

You can return it in person to:
- the Town Hall, Walliscote Grove Road, Weston-super-Mare
- any North Somerset Library
- the For All Healthy Living Centre, Lonsdale Avenue, Weston-super-Mare

The technology involved in printing passes means that we cannot print them instantly for personal callers. However, we can accept and check application forms at any of the above locations, forms will then be forwarded to the Diamond Travelcard Office where they will be printed and dispatched.

Please attach a recent passport sized photograph to your application. 
The photo should show head and shoulders only with no headgear. 
Please print your name on the back in case it gets separated.



Checklist
Section A to be completed by all applicants
Section B to be completed by all applicants
Section C all applicants to complete the relevant criteria
Section D additional information
Section E application for a companion travelcard
Section F to be completed by all applicants



*****SECTION A - PERSONAL DETAILS (to be completed by all applicants)*****

Title: [] Mr [] Mrs [] Miss [] Ms [] Other [] Please state:
Surname: 
Forenames:
Sex: [] male [] female
Date of birth:
National Insurance number:
Address:
Postcode:
Telephone:
Mobile:
Email:
Is the above address your sole and principal residence for more than six months of the year? [] Yes [] No
If no, please contact the local authority of your principal residence to obtain a travelcard.
Would you like to receive correspondence in large print? [] Yes [] No



*****SECTION B - ELIGIBILITY ASSESSMENT (to be completed by all applicants)*****

Please refer to the relevant criteria in Section C to find out what evidence you need toprovide to prove your eligibility. You will need to send this to us with your application form.
We accept photocopies.
You will only be eligible if your disability is permanent, i.e. it has affected you and/or will affect you for at least six months.

I am eligible for a Diamond Travelcard because I suffer from the following disability (please tick):
[] Criteria 1: Profoundly or severely deaf
[] Criteria 2: Severe disability in both arms
[] Criteria 3: Severely disabled and unable to walk
[] Criteria 4: Blind or partially sighted
[] Criteria 5: Significant learning disability
[] Criteria 6: Have been refused a driving licence due to physical or mental incapacity
[] Criteria 7: Without speech



*****SECTION C - PROOF OF ELIGIBILITY (all applicants to complete the relevant criteria)*****

National Criteria 1: Profoundly or severely deaf

Criteria:
- The applicant has a hearing loss of 70 dbHL or above.

Proof:
Please tick as appropriate and attach your proof to the application form.
1A I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).



National Criteria 2: Severe disability in both arms

Criteria:
- The applicant does not have arms or has the long term loss of the use of both arms.

Proof:
Please tick as appropriate and attach your proof to the application form.
2A I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).



National Criteria 3: Severely disabled and unable to walk

Criteria:
- To be eligible you must receive the Higher Rate Mobility component of Disability Living Allowance or have a disability at a comparable level.
- You will need to provide evidence that you walk with excessive labour and at an extremely slow pace or with excessive pain.
- Difficultly in carrying parcels will not be taken into account.
- If you use a walking aid or can walk relatively normally with an artificial leg then you may not qualify.

Proof:
Please tick as appropriate and attach your proof to the application form.
3A I receive Higher Rate Mobility component of Disability Living Allowance (DLA) []
- Please provide evidence (e.g. official letter of entitlement from DLA) less than 12 months old showing the period it covers unless you are entitled to receive this
allowance indefinitely.
- If the DLA award is for less than 12 months you may not qualify.
- We cannot accept Lower Rate Mobility Component or any level of Care Component as proof of Criteria 3.
3B I receive a War Pensioner’s Mobility Supplement []
- Please provide evidence less than 12 months old (e.g. official letter) showing the period it covers.
- If the award is for less than 12 months you may not qualify.
3C I have a Blue Badge []
- Please provide the expiry date of your Blue Badge:
- We will check with the Blue Badge department to confirm you are eligible.
- If your Blue Badge expires within six months, please supply medical evidence (see below).
3D I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).



National Criteria 4: Blind or partially sighted

Criteria:
- The applicant is unable to read the top letter in the eye test chart (used by opticians) with their glasses, if worn, at a distance of 6 metres or less.

Proof:
Please tick as appropriate and attach your proof to the application form.
4A I am registered with the council []
- We will contact the relevant department in the council to confirm that you are eligible.
4B I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).



National Criteria 5: Significant learning disability

Criteria:
- The applicant suffers from a state of arrested or incomplete development of mind which includes significant impairment of intelligence and social functioning.
- Those affected will have a reduced ability to understand new or complex information, a difficulty in learning new skills, and may be unable to cope independently.
- These disabilities must have started before adulthood and have a lasting effect on development.

Proof:
Please tick as appropriate and attach your proof to the application form.
5A i) I live in a council-run residential care home []
- The name of the home is:
- We will check this against our list of North Somerset care homes.
ii) I live in a privately-owned residential care home []
- The name of the home is:
- Please attach a letter on headed paper from the manager of your care home.
5B I receive services from the council’s Learning Disabilities Team or Children’s Disabilities Team []
- We will contact these teams to confirm that you meet the above criteria.
5C I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).
5D I attach a letter from my social worker or key/support worker []
- Please provide a letter that explicitly states that you meet the criteria outlined above.
- Letters should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).



National Criteria 6: Have been refused a driving licence due to physical or mental incapacity

Criteria:
- The applicant has a condition that prevents them from holding a driving licence.
- The applicant would be refused a licence under Section 92 of the Road Traffic Act 1988.
- This criteria does not include refusal on grounds of drug or alcohol misuse.
- Medical conditions that may prevent someone holding a driving licence include epilepsy (except when free of seizures for a year), restricted visual fields, cardiac or neurological disorders or severe mental disorders (e.g. bipolar or schizophrenia).

Proof:
Please tick as appropriate and attach your proof to the application form.
6A I have surrendered my driving licence or had it revoked []
- Please provide a letter from the DVLA confirming your licence has been revoked.
- When can you reapply for your licence?
6B My application for a driving licence would be refused on medical grounds.
I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).
6C I have a severe mental disorder and am a patient with Avon and Wiltshire Partnership []
- We will check with Avon and Wiltshire Partnership to confirm that you meet the above criteria.



National Criteria 7: Without speech

Criteria:
- The applicant is unable to communicate orally in any language.
- They are unable to make basic oral requests or to ask specific questions to clarify instructions.
- People with a stammer or those for whom English is not their first language will not be eligible.

Proof:
Please tick as appropriate and attach your proof to the application form.
7A I attach medical evidence []
- Please provide medical evidence that explicitly states you meet the criteria outlined above.
- Medical evidence can be in the form of a letter or report from your consultant or GP.
- Medical evidence should be dated and provided on headed paper.
- We cannot accept evidence that is out of date (i.e. more than 12 months old).



*****SECTION D - ADDITIONAL INFORMATION*****

Please provide us with any information you think we should know that is not covered elsewhere in your application:
We cannot accept anything written here by a professional as evidence of your disability.
Medical evidence or professional letters must be dated and written on headed paper and attached to this form.



*****SECTION E - APPLICATION FOR A COMPANION DIAMOND TRAVELCARD*****

I would like to apply for a companion pass as I need the assistance of a companion at all times when travelling.  []Yes

I can confirm that the applicant has a disability and is unable to travel on public transport without the aid of a companion for the duration of the journey.  []Yes

Name and address of GP or consultant:
Telephone number:
Signature:

This benefit is provided at the discretion of the council, and North Somerset Council reserves the right to change or withdraw this benefit at any time. 
Children under the age of 11 cannot apply for a companion card.



*****SECTION F: DECLARATION (to be completed by all applicants)*****

[] I declare that, to the best of my knowledge, all the information I have provided is correct.

Signed:
Date:



Data protection:
This information will be used by North Somerset Council, the Department for Transport, bus operators, and appointed contractors to administer the Diamond Travelcard service and may be used to monitor bus usage. It may also be used internally for research into travel services. Your name and other identification details may also be used in the council's contact centre for the purposes of improving your access to any of the council's services. The Diamond Travelcard itself will only hold your name, pass number and expiry date.

The council is under a duty to protect the public funds it administers and may use information you have provided in order to prevent and detect fraud. We may, therefore, also share this information with other bodies responsible for auditing or administering public funds for this purpose, including the Audit Commission, and the council's auditors. Please contact the council's Corporate Information Management team for any queries about data protection.



***FOR OFFICE USE ONLY***

[] Photo
[] Proof of residence

Proof of disability:
[] HRMA of DLA
[] Medical evidence
[] War Pensioners' Supplement
[] Other:
[] Referred to GP/consultant
[] Card expiry date:
	[] Permanent
	[] Time limited:
[] Companion evidence

Initials:
Account number:
Date of assessment:
Date of issue: