## Application Form For The London Taxicard Scheme Section 1 - Personal  Details

IMPORTANT: You must supply correct proofs. See the accompanying 'Guidance to the completion of the Taxicard application form'. Please complete your details in BLACK INK AND CAPITAL LETTERS.

Section 2
PHOTOGRAPH
Taxicard provides subsidised transport in taxis and private hire vehicles
(mini-cabs) for people who have severe mobility or visual impairments and
who find it very difficult or impossible to use mainstream public transport
such as buses and tubes.
PLEASE ENCLOSE 
ONE COLOUR
PASSPORT SIZE
PHOTOGRAPH 
TAKEN WITHIN THE 
LAST 12 MONTHS
The service is managed by London Councils on behalf of all London Local
Authorities. For more information about the Taxicard Scheme please visit:
www.londoncouncils.gov.uk/services/Taxicard
Contact us: Email: taxicard@londoncouncils.gov.uk
Telephone: **020 7934 9791** (option 2)

## Section 3 - Automatic Qualification

IMPORTANT: You must supply evidence that you meet one of the automatic qualification criteria. 

See the accompanying 'Guidance to the completion of the application form'. 

I claim that I am eligible for the Taxicard scheme because: 
PLEASE TICK ONE BOX ONLY IN THIS SECTION
I receive 8 points or more for the moving around activity component of PIP and I attach a photocopy of my letter of entitlement, including the front page and pages that show the points breakdown I receive the Higher Rate Mobility Component of the Disability Living Allowance and I attach a photocopy of my letter of entitlement.

I am registered severely sight impaired/blind and I attach a photocopy of evidence of registration with my Local Authority, e.g. CVI
I receive the Armed Forces Independence Payment (AFIP) and I attach a photocopy of my letter of entitlement.

I receive a War Pension Mobility Supplement and I attach a photocopy of my letter of entitlement.

I receive the Higher Rate Attendance Allowance and **I attach a photocopy of my letter of entitlement.***
*Not all London Boroughs accept this benefit as an automatic qualifier.  See the accompanying 'Guidance to the completion of the Taxicard application form (page 2, section 3), to see whether your borough accepts this.

Age (only in certain boroughs) - if you are 80 years of age or older in Islington / if you are 85 years of age or older in Barnet or Redbridge / if you are 90 years of age or older in Kingston. Please note that age is not an automatic criterion in any other borough.

Blue Badge - in Hammersmith & Fulham only. Having a Blue Badge is not an automatic criterion in any other borough.

## Medical Evidence

If you do not meet one of the automatic criteria in Section 3 you will need to be assessed by your local council or their contracted assessment company. 

You must provide medical evidence dated within the last 12 months which supports why you need a Taxicard. This could be a copy of a discharge or medical summary, GP or consultant letter or occupational therapist report.

If you are in receipt of any other disability benefits, please list these here:
All applicants must complete every section of this form, as it will assist with your assessment, and may determine the number of Taxicard trips you are allocated. Failure to do so may result in delays to your application or your application being returned to you.

## Section 4 - Transport Services

A) Public transport services: Please indicate whether you use (or could use if you wished to) any of the following public transport services, ticking either the yes or no box after each service.

PLEASE TICK AS APPROPRIATE

| Trains   |
|----------|
| Y        |
| Trams    |
| N        |
| Y        |
| N        |
| Y        |
| N        |
| Y        |
| N        |

You can find out more about public transport services by telephoning Transport for London on 0343 222 1234
or on the website www.tfl.gov.uk.

B) Other transport services: We would like to know what other assisted transport you have available to you.

Please indicate whether or not you use any of the following services, ticking either the yes or no box after each service.

PLEASE TICK AS APPROPRIATE
Comments
Older Person's Freedom Pass
N
Y
Disabled Person's Freedom Pass
N
Y
Scooter loan scheme
N
Y
Access to Work scheme
Y
N
Community Transport Services
Y
N
Social Services Transport to Day Centre
Y
N
Shopmobility scheme
Y
N
Motorbike/Scooter
Y
N
Taxis
Y
N
Private Hire Vehicles
Y
N
Friend's/Relative's Vehicles
Y
N
Residential Home Transport
Y
N
London Dial-a-Ride
Y
N
Other

If you want to find out whether specific schemes operate in your area please contact your council.

## C) Disabled Persons Parking Schemes

Do you have a disabled person's parking permit?
Y
N

If you have a blue / red / white / purple badge  (delete as appropriate)
Enter the Serial Number here:

Issuing Authority
Are you a driver?
Y
N
Or both?
Y
N
Or passenger?
Y
N
When does the badge expire?
D D M M Y
Y
Y
Y

## Section 5 - Your Health/Disability

If you do not meet one of the automatic criteria in Section 3, please provide a copy of medical evidence from a health care professional to support the statements in Section 5 and 6. Failure to do so may lead to a delay in your application.

## What Are Your Health/Mobility Difficulties? Please Explain How They Affect Your Use Of Public Transport.

How long have you had the above? (circle the applicable number of years)
Less than 1 year  /  1-2 years  /  2-4 years  /  6-8 years  /  8-10+ years  /  lifetime How often is your ability to use public transport affected in this way? (please tick)
All the time Sometimes If sometimes, how often?

## Section 6 - Getting Around Outside

The following questions are to help us understand your mobility difficulties outside of your home.

## A) Your Mobility

Are you able to stand?

Y
Do you have difficulty in standing?

Y
0-5  /  5-10  /  10-20  /  20-30  /  30-40  /  40-60+
If yes, how long are you able to stand?

(circle the applicable number of minutes)
What prevents you from standing longer?

How far can you usually walk in metres or yards?

(This includes when using a walking aid)
Can you climb steps and stairs without difficulty?

Y
N

## B) Use Of Wheelchairs/Walking Aids Outside.

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, the customer 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 if any of the following apply to you

## Manual Wheelchair

Do you use a manual wheelchair?
Y
N
Can you transfer to a seat when travelling?
Y
N
Do you rely on someone else to push you in
your manual wheelchair? 
Y
N
My manual wheelchair was
recommended by
Does your manual wheelchair have 
leg extensions? 
Y
N

## Powered/Electric Wheelchair

Do you use  a powered/electric wheelchair?
Y
N
Can you transfer to a seat when travelling?
Y
N
Manufacturer
Model
My powered/electric wheelchair was
recommended by:
Does your powered/electric wheelchair have leg extensions?
Y
N

## Mobility Scooter

Do you use a mobility scooter?
Y
N
Can you transfer to a seat when travelling?
Y
N
Manufacturer
Model

## Outside Walking Aids

Sometimes
Always
I use a walking frame: 
Sometimes
Always
I use a walking stick: I use other walking equipment/aid 
(please specify)
Sometimes
Always
I use this equipment: My walking equipment/aid was
recommended by

## Section 7 - Communication

Please indicate if any of the following apply to you (please tick) 
I am severely visually impaired/blind I would prefer to be contacted in the following format:
Large Print Audio Braille I am hard of hearing I am profoundly/severely deaf I have a speech impairment

## Section 8 - Ethnic Origin* Tick The Relevant Box

(e) Other 
Ethnic Group
(d) Asian or Asian British
(c) Mixed
(b) Black or
Black British
(a) White
British
Caribbean
Indian
Arab
White/Black 
Caribbean
Irish
African
Pakistani
White and 
Asian
Bangladeshi
Gypsy or Irish Traveller
White/Black African
Chinese
Any other Mixed
please write 
in above
Any other Asian
please write 
in above
Any other please write 
in above
Any other White
please write 
in above
Any other Black
please write 
in above
I do not wish to say

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' above.

* These categories are taken from Census 2011.

## Section 9 - Data Protection

What information do we collect?

We collect the following information about you; Name, address, date of birth, gender, photograph, email address, phone number, national insurance number, ethnic origin, blue badge number, details of mobility, details of other schemes you may use, details of any person with legal responsibility for applicant, evidence of benefit entitlement. Once a member of the scheme, we collect booking information, journey details, records of payment taken for replacement passes and fare underpayments. If you telephone London Councils Taxicard and CityFleet (the contracted vehicle provider) your call will be recorded for training and quality purposes.

Why do we need it?

We use the information to assess if you are eligible for a Taxicard and, if you are eligible, to manage the scheme. We may also use it to prevent fraud, to promote and achieve equal opportunities and to improve the scheme (including to assess the services available to Taxicard users). 

Who do we share your information with?

Your information will be shared with the London borough in which you reside. The London borough may share it with a company contracted to conduct mobility assessments. We will also share it with external providers who provide the booking system, vehicles and customer relationship database.

How long do we keep your information for?

We keep successful applications information for as long as you use the Taxicard service and 3 years afterwards. 

We keep unsuccessful applications for 3 years. We keep call recordings for 6 months. We keep journey details for 7 years; these are required for audit purposes. 

Who is responsible for your information?

London Councils and the London borough in which you reside are separately responsible for making sure your information is managed properly. 

What you can do with your information?

You can ask what information we have about you. You can ask us to change anything that is inaccurate. You can ask us to stop processing your information but you will no longer be able to use your Taxicard. 

Can I get some more information?

A more detailed privacy notice is available on the Taxicard website or please call 0207 934 9791 if you would like a copy posted to you. You can also email dataprotection@londoncouncils.gov.uk if you have any questions or concerns about how your information is used. 

## Section 10 - Proof Of Identity And Residence

You must provide ONE example from Section 10a and ONE example from Section 10b below as proof of identity and residence. Please tick the box next to the evidence provided. (These should be photocopies. Please do not send originals as these cannot be returned to you)

## Section 10A - Identity

Copy of current Passport
Copy of photocard or paper Driving Licence Copy of Birth Certificate (unless your name has changed) Copy of Marriage/Divorce Certificate
Copy of European Identity Card Copy of Asylum Registration Letter

## Section 10B - Residence

(If you do not receive paper bills, we will accept a print out of a dated online statement)

Copy of current Council Tax Bill/Letter/Payment Book (dated in the last 12 months)
Copy of current Council Housing Association Rent Book/Statement/Letter (dated in the last 12 months) Copy of tenancy agreement (dated in the last 12 months)
Copy of home or contents insurance documents (dated in the last 12 months)
Copy of current Television Licence/exemption letter (dated in the last 12 months)
Residential utility bill/letter (excluding mobile phone bill) e.g. gas, electricity, phone, water *

(dated in the last 3 months)

Copy of domiciliary care bill * (dated in the last 3 months) Copy of letter of entitlement to benefits or pension * (dated in the last 3 months) Copy of HM Revenue and Customs letter * (dated in the last 3 months)
Please note that if the application form is incomplete or you do not provide the required supporting documentation it will be necessary to return it, leading to a delay in processing your application. Please ensure the evidence provided is within the specified timescales.

| CHECKLIST                                                           |  I ENCLOSE:       |
|---------------------------------------------------------------------|-------------------|
| PROOF OF ENTITLEMENT                                                | PROOF OF IDENTITY |
| AND RESIDENCE                                                       |                   |
| ONE PASSPORT SIZED COLOUR PHOTOGRAPH                                |                   |
| MEDICAL EVIDENCE (if you do not meet one of the automatic criteria) |                   |

* The cost (if any) of any medical evidence provided will not be reimbursed by your local authority
or London Councils

## Section 11 - Declaration

I declare that the information given on this form is true in all respects. Should any changes occur in my mobility needs, I will inform my local council immediately. I understand that you may prosecute me if I have given any information on this form, which may be wrong or untrue, or any supporting documentation, which is false or fraudulent. I acknowledge that I have read, understand and accept the Taxicard conditions of use which are located in the accompanying 'Guidance to the completion of the Taxicard form' and on the Taxicard website at:
www.londoncouncils.gov.uk/services/taxicard If you are unable to sign the declaration yourself it may be signed on your behalf by your relative/spouse/
person of authority/friend. If you are under 16 years of age your parent or legal guardian must sign this form.

Please return this form to:

Please make sure you pay the correct postage to
ensure your application is delivered. It will cost
more than one 1st class stamp. You can find the
exact cost at www.royalmail.com/price-finder or 
by visiting your local post office.