DIAMOND TRAVELCARD APPLICATION FORM

If you need this form in a different format or language please contact:

Travelcard Office
North Somerset Council
Somerset House
Oxford Street
Weston-super-Mare
BS23 1TG

Tel: 01934 426 426

diamond.travelcard@n-somerset.gov.uk

If you are filling this form in on a computer, you will need to print it off and sign it and send it to us in print with all the other evidence we need.

Title:

First name:

Middle name(s):

Last name:

Gender:

Date of birth:

House number/name:

Street:

Village:

Town:

Postcode:

Telephone (including dialling code):

Email:


PLEASE ATTACH A RECENT PASSPORT SIZE PHOTOGRAPH TO THIS FORM
- The photo should be head and shoulders with no headgear
- Please print your name on the back in case it gets detached

Would you like to receive future correspondence in large print?


I qualify for the following reason:

Please put an ‘X’ by the appropriate statement

I am aged 60 or over:

Or:

Choose ONE option that indicates your MAIN disability

-I am blind or partially sighted:

-I am profoundly or severely deaf:

-I am without speech:

-I have a long term disability or injury that prevents me from walking:

-I have no arms or lack the use of both arms:

-I have a learning disability:

-I am unfit to drive due to a medical condition:

If you are unable to travel on buses alone and need a companion pass put an 'x' here: 

-Please note that applications for a companion pass need to be accompanied by medical evidence.


If you are not an existing bus pass holder please provide evidence of eligibility.

PROOF OF ADDRESS e.g. a recent utility bill

PROOF OF AGE e.g. birth certificate or passport or driving licence or pension entitlement

OR

PROOF OF DISABILITY e.g. higher rate mobility component of disability living allowance, registration with the Council or medical evidence


Previous pass number (if any):


Declaration

*	I wish to obtain a concessionary Diamond Travelcard.

*	I declare that I am eligible and will abide by the conditions of the scheme as detailed in the current Diamond Travelcard booklet.

*	I am permanently resident in North Somerset and entitled to a pass for free bus travel.

I declare that the information I have given on this form is correct. I understand that if I lose my new Diamond Travelcard there may be a £5.00 replacement fee.


Signed:

Date:

Remember to send the following with your application
*	Passport size photograph (write your name on the back)
*	Proof of eligibility
*	Proof of residency 

Send your application to:

Travelcard Office 
North Somerset Council
Somerset House
Oxford Street
Weston-super-Mare
BS23 1TG

Tel: 01934 426 426

diamond.travelcard@n-somerset.gov.uk

www.n-somerset.gov.uk/diamondtravelcard