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You must complete the form in black ink and capitals. 

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## Taxicard Application Form - London Borough Of Hounslow

The Taxicard scheme provides subsidised travel in participating licensed taxis (black cabs) and private hire vehicles (minicabs) across the capital. You will qualify automatically if you receive certain disability-based benefits, or if you are severely sight-impaired (blind). You may also qualify if you have a substantial and long-term mobility problem which prevents or seriously affects your ability to use public transport. The scheme is managed by London Councils on behalf of participating London Boroughs.                             

## Section 1 - Personal/Contact Details

Title            First and Middle Names                          Last Name 

 
Please attach one colour passport sized photograph taken within the last three months 
Email: 

## Section 2 - Automatic Eligibility

Please tick if one of the following applies:-       

 
I receive the High Rate Mobility Component of Disability Living Allowance (DLA) - I attach 
my most recent award letter.  
 
I receive 8 points or more in the 'Moving Around' category of the Mobility Component of 
Personal Independence Payments (PIP) - **I attach my most recent award letter.** 
 
I receive the War Pension Mobility Supplement, or a lump sum in Categories 1-8 of the 
Armed Forces Compensation Scheme and have been certified as having 'a permanent and substantial disability which causes inability to walk or very considerable difficulty 
walking'– **I attach my most recent award letter.** 
 
I am severely sight-impaired (blind) - I attach a Certificate of Visual Impairment (CVI) 
signed by an Ophthalmologist, or a letter from Hounslow Council confirming that I am registered with them as severely sight-impaired.  

## Section 3 - Transport Services



A) Please tick which of the following modes of transport (if any) you have used within the last 
12 months: Dial-a-Ride             Train              Tube            Buses (of any kind) 
B) We would like to know what other types of assisted transport services you have available to you. Please tick if you use any of the following: Access to work scheme          Community transport services Older Persons Freedom Pass           Disabled Persons Freedom Pass Social Services transportation           Taxis/Minicabs            Friends/relatives vehicles Other (please specify): ______________________________________________________ 
C) Do you have any difficulties, or need any assistance in using, any of the above? If so, please give details below: If you have any enquiries regarding using public transport in London as a disabled person please contact Transport for London (TfL) on 0343 222 1234, or alternatively via email at tflaccessibility@tfl.gov.uk 
 
D) Do you hold a Disabled Persons Parking Badge? (Blue Badge)   Yes            No If so, which local authority issued it? _____________________________________________ Please enter the serial number below And the date of expiry                      How often do you use your badge, and what for? 

 
__________________________________________________ Do you own a driving license?         Has your badge been issued within the last six months? 



Yes              No                                Yes              No IF YOU MEET ONE OF THE AUTOMATIC CRITERIA LISTED IN SECTION 2 PLEASE GO STRAIGHT                             TO SECTION 8 

## Section 4 - Health And Mobility

 
A) Please list any medical conditions/disabilities you have which impact on your health/ability to move around, and provide evidence of this (eg GP/Consultant letters, hospital reports or similar). Medical condition/disability                                                       How long have you had this? 



B) Do you take any prescribed medication for the above? This could include things like inhalers, sprays, injections etc. Yes           No           If yes, please attach copies of prescriptions. 

 
 
C) Do you receive any specialist treatments or therapies for the above? This could include things like pain management clinics or regular physiotherapy.   Yes           No 
 
 
If yes, list below                                                                        How often do you receive it? 



D) Are you on the waiting list for any surgery? (e.g. orthopaedic, heart, other)   
 
 
Yes         No         If yes please give details: ______________________________________ 
 
E) Please explain how your medical condition/disabilities impact on your ability to use public transport: 

## F) How Often Is Your Ability To Use Public Transport Affected In This Way?

All the time             Sometimes             If sometimes, how often?  _____________________ 

## Section 5 - Moving Around Outside

 
A) (i) Are you able to stand?  Yes        No                                              

   (ii) Do you experience any difficulty standing?  Yes         No  

  (iii) If yes, how long are you able to stand for? ___________________________________ (iv) What prevents you from standing longer? 
 
 
B) How far can you usually walk in metres or yards? This includes using walking aids.  
(Length of a bus = 15 metres - length of a football field = approximately 100 metres) 

 
 
C) What prevents you from walking further? 
 
D) Can you climb steps and stairs without difficulty?    Yes         No   
 
 
If not, please explain your difficulty: 

 
 
E) Please tick which of the following apply to you: 
I use a walking frame:   Sometimes          Always          Never  
 
       
 
I use a walking stick:   Sometimes          Always          Never 


I use other walking equipment (please specify): ___________________________________ I use this equipment:   Sometimes          Always  
 
 
My walking aid was recommended by: __________________________________________ _________________________________________________________________________ 

## Section 6 - Activities Of Daily Living

 
A) Do you experience difficulties in carrying out everyday activities in your home? (eg personal care, cooking, cleaning).   Yes        No         If yes, please provide details below: 

 
 
B) Have you been provided with any equipment to help you carry out these activities?   
Yes        No         If yes, please provide details below: 

 
 
C) Has your home been adapted in any way to help you carry out these activities?  
Yes        No         If yes, please provide details below: 

 
 
 If you have previously been assessed by your local council for any home adaptations please provide us with a copy of your assessment (if available). 

## Section 7 - Referees

 Please provide details of a healthcare professional/social worker who knows about your mobility problems and who may be contacted for more information if needed.   
Name:                                                            Position: Address: Email: Postcode:                                                     Telephone: 
 
If you provide enough supporting medical evidence it is unlikely that your nominated referee will be contacted. 

## Section 8 - Wheelchairs/Mobility Scooters

 To ensure your safety, if you need to use a wheelchair when travelling in a licensed London taxi you must travel facing the rear of the taxi with your back to the partition and use the attachment belts provided. Many larger electric wheelchairs cannot be positioned and safely secured in this way, due to their size, and so are unsuitable for use when travelling on the Taxicard scheme. Many mobility scooters cannot be safely secured or are too heavy to use the ramps in licensed London taxis and therefore cannot be used when travelling on the Taxicard scheme. However, you can travel if the electric wheelchair can be safely secured and the scooter is not too heavy and the customer can transfer from it to the back seat of the taxi in order to travel. If you use a wheelchair or scooter, we need some additional information from you so that we can establish the best way that we can provide the Taxicard service for you. Our ability to provide a suitable vehicle for you will be limited if you do not have access to a wheelchair of a type which can be safely secured in a London taxi and you are not able to transfer to a seat when travelling. Please tick which of the following (if any) apply to you: 

## A) Manual Wheelchairs

Do you use a manual wheelchair?   Yes           No  
 
 
If yes, can you transfer to a seat when travelling?  Yes          No 
 
 
If yes, do you rely on someone else to push you?  Yes          No 
 
 
If yes, who recommended it to you? __________________________________________ _______________________________________________________________________ 
Does it have leg extensions?   Yes           No 

## B) Powered/Electric Wheelchairs

Do you use a powered/electric wheelchair?   Yes            No 
 
 
If yes, can you transfer to a seat when travelling?  Yes            No  
 
     
If yes, please advise us of it's: 
Manufacturer: _________________________ **Model:** ___________________________ 
If yes, who recommended it to you? __________________________________________ 

_______________________________________________________________________ 

Does it have leg extensions?   Yes           No 

## C) Mobility Scooters

Do you use a mobility scooter?   Yes            No 
 
 
If yes, can you transfer to a seat when travelling?  Yes            No  
 
     
If yes, please advise us of its: **Manufacturer:** _____________ **Model:** _______________ 
If yes, who recommended it to you? __________________________________________ 

_______________________________________________________________________ 

Does it have leg extensions?   Yes           No 
 

 

## Section 9 - Proof Of Identity And Address

 
In order for us to process your application you **must** provide: 

A) **ONE COLOUR PHOTOGRAPH** - passport-sized and dated within the last 3 months. B) **ONE PROOF OF IDENTITY** - a **copy** of one of the following (please tick): 



*Birth / Adoption Certificate  
 
Current driving license (paper counterpart is no longer valid) Passport / EU Identity Card NHS Medical Card HM Forces ID Card *Civil Partnership / Dissolution Certificate *Naturalisation Certificate 
 
*Marriage / Divorce Certificate  

 
*The name on the proof of identity and the proof of address **must** match. 

## C) One **Proof Of Address** - A **Copy** Of One Of The Following (Please Tick):

| Current Council Tax Bill/Letter/Payment B                  | ook    |
|------------------------------------------------------------|--------|
|                                                            |        |
|                                                            |        |
| Current Council/Housing Association Rent B                 | ook    |
|                                                            |        |
|                                                            |        |
| Valid Television Licence/exemption letter                  |        |
|                                                            |        |
| Valid tenancy agreement -                                  |        |
| dated within 12 months                                     |        |
|                                                            |        |
|                                                            |        |
| Home or contents insurance letter                          | -      |
| dated within 12 months                                     |        |
|                                                            |        |
|                                                            |        |
|                                                            |        |
| Residential utility bill (excluding mobile phone bills) -  |        |
| dated within 3 months                                      |        |
|                                                            |        |
|                                                            |        |
| Copy of HM Revenue and Customs letter -                    |        |
| dated within 3 months                                      |        |
|                                                            |        |
|                                                            |        |
| Letter showing letter of entitlement to benefits/pension - |        |
| dated within 3 months                                      |        |
|                                                            |        |
|                                                            |        |
| Domiciliary Care Bill -                                    |        |
| dated within 3 months                                      |        |
|                                                            |        |
|                                                            |        |

## Section 10 - Communication

 In case we need to contact you regarding your application, we will try to accommodate any communication needs that you may have. Please tick if one of the following applies to you: I am hard of hearing 
 
I am profoundly/severely deaf  
 
I have a speech impairment        If you do, please describe it: ________________________ 
 
_________________________________________________________________________ English is not my first language and I need an interpreter  
 
If you need an interpreter or someone to help with the application process and you know someone who can do this for you, please give us their name, address and telephone number. 

Full Name: 
Address: 
 
Postcode:                                           Telephone: 
Mobile:                                                Email: 
 

## Section 11 - Ethnic Monitoring

 
The purpose of this section is to provide information on whether we are delivering services in an appropriate manner across the whole community. This information is confidential and failing to complete it will not prejudice your application. If you do not wish to fill it in please tick the box 'I do not wish to say' in category F below. These categories are taken from Census 2011. 

A) White - British        Irish        Gypsy/Irish traveller       Other: _______________________ 


B) Black or Black British - Caribbean         African        Other: _______________________ 
      
 
C) Mixed - White/Black Caribbean          White/Asian        White/Black African 
 
  
  
Other mixed (please state) ____________________________________________________ 
D) Asian or Asian British - Indian        Pakistani        Bangladeshi        Chinese  

 
  
Other Asian or Asian British: ___________________________________________________ 
 
E) **Other** - Arab        Other: ____________________________________________________ 
 
F) I do not wish to say:  
 

## Section 12 - Declaration

 I accept that all personal information and supporting evidence I provide in relation to my application for a Taxicard may be shared between Hounslow Council, London Councils (who administer the scheme) and third parties involved in assessing my eligibility. I also accept that my contact details may be made available to those providing the service. I acknowledge that this information will be handled in line with the Data Protection Act 1998. I accept that the duty Hounslow Council is under to protect the public funds it administers may lead to it cross referencing this information with other Council departments, or sharing it with third parties, for the prevention and detection of fraud. I accept that I may be required to attend a mobility clinic as part of my assessment. I declare that I will not use Taxicard for trips where other subsidies are available, and that I will abide by the 'Taxicard terms and conditions of use' located at the end of the guidance notes which accompany this form. I declare that the information given on this form is true and accurate to the best of my knowledge. Should my mobility improve significantly, or I stop receiving one of the qualifying benefits, I will inform you as soon as is reasonably possible. I understand that you may prosecute me if you believe that I have deliberately given incorrect information or fabricated or doctored any evidence provided as part of my application.  
 
Signature                                                                            Date 


Print name                                                


If you are unable to sign the declaration yourself it may be signed on your behalf by a relative/spouse or legal representative. If you are under 16 years of age your parent or legal guardian must sign this form. 

Relationship to applicant (if signing for someone else)   Contact phone number 
 
      
 
 
Your information may be used to contact you about initiatives which we believe to be of direct benefit to you or to consult you about the Taxicard Scheme, with the aim of improving the service. If you do not wish to receive this information or to be consulted, please indicate below by ticking the box provided. I am willing to be consulted:   Yes          No             
  
  
  
  
I am willing to be contacted regarding other services and initiatives:   Yes           No How did you hear about the Taxicard scheme? If you have any enquiries about this application form, please contact London Councils on: Tel: (020) 7934 9791 (Mon-Fri 9am-5pm) or via email at taxicard@londoncouncils.gov.uk  

## Section 13 - Checklist

  
  
  
  
  
Please return this form to:
London Councils Taxicard Section 59 ½ Southwark Street London, SE1 0AL 

 
Make sure that you enclose the following (please tick): Proof of eligibility (if you completed Section 2): Supporting medical evidence (if non-automatic): Proof of identity: Proof of address: One colour photograph: 
Please note that Taxicard applications can take up to 6/8 weeks to process. 

## For Office Use Only

 
Authorising Officer                                           **Taxicard Number**                                                             

                                                    
                                                                                         
Signature                                                           Date