Declare and sign
Please read through each declaration and tick both boxes below to show you have read, understand, and agree with this declaration. Not ticking one of these declarations may mean we are unable to issue you with a Disabled Person’s Travel Pass.
I confirm that, as far as I know, the details I have provided are complete and accurate.
I realise that I will not be entitled to a Disabled Person’s Travel Pass if I have provided false information.
I confirm that the photograph I have provided is a true likeness.
I understand I must tell you about any changes that may affect my entitlement to a Disabled Person’s Travel Pass, including any change of address, as soon as possible.
I understand that you will deal with all documents relating to this application in line with General Data Protection Regulations and you may share them with other local authorities and the police to detect and prevent fraud.
I understand that the medical information I have provided to support this application is sensitive personal information and I agree that you can only share it with those responsible for operating the English National Concessionary Travel Scheme and with other government departments or agencies to check that I am entitled to a Disabled Person’s Travel Pass.
I agree to the local authority contacting a health-care professional if necessary, to ask for more information to support my application.
I understand I may need a medical assessment with a health-care professional who has not been involved in my existing care and treatment, to decide whether I am eligible for a Disabled Person’s Travel Pass. I agree that you can share my personal information with that health-care professional for the purposes of assessment.
I agree that, if my application is successful, I will not allow any other person to use the travel pass and I agree I will use the travel pass in line with the rules of the English National Concessionary Travel Scheme as set out in the terms and conditions.
By typing your name electronically in the signature box on this application form you agree, acknowledge and intend that this will constitute your signature for the purposes of this application.
Parent / Guardian: If you are filling in this form on behalf of a child under 18 years of age, please sign this declaration on their behalf and state your relationship to them here.