## 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.

TAXICARD The Taxicard is a travel concession permit for eligible persons. The service is managed by London Councils on behalf of all London Local Authorities. For more information about the Taxicard Scheme please visit: www.taxicard.org.uk or contact us: by email: taxicard@londoncouncils.gov.uk By telephone: 0845 415 4156

## Section 3 - Automatic Qualification

IMPORTANT: You must supply correct proofs. See the accompanying 'Guidance to the completion of the Taxicard application form'. I claim that I am eligible for the Taxicard scheme because: 
PLEASE TICK ONE BOX ONLY IN THIS SECTION
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. 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 to see whether your borough accepts this.

I receive 8 points or more for the moving around activity component of PIP and I attach a photocopy of my letter of entitlement.

## Section 3A - Other Benefits Received

If you are not in receipt of the above benefits and are not registered as a blind person or as someone with a severe visual impairment, you may need to be assessed by your local council's mobility assessor. Please complete the rest 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.

If you are in receipt of any other disability related benefits, please list these here:

## Section 4 - Transport Services

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

PLEASE TICK AS APPROPRIATE
Comments
London Dial-a-Ride
N
Y
Trains
N
Y
Tubes
N
Y
Buses (any type)
Y
N

You can find out more about public transport services by telephoning Transport for London on 020 7222 1234.

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
Council Transport Voucher
(if scheme is available in your area)
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
Other (e.g. Tram, please specify)

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

## C) Blue Badge Disabled Persons Parking Scheme

Do you have a Blue Badge Parking Permit?
Y
N
If you have a Blue Badge please 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 A) What Are Your Health/Mobility Difficulties?

| How long have you had the above?   | Years   | Months   |
|------------------------------------|---------|----------|

## B) Please Explain How Your Health/Mobility Difficulties Affect Your Ability To Use Public Transport?

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
N
Do you have difficulty in standing?
Y
N
If yes, how long are you able to stand?

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

Is there anything else you would like to tell us about your mobility difficulties outside the home?

## B) Use Of Wheelchairs/Walking Aids Outside. Please Tick If Any Of The Following Apply To You (Please Tick)

I use a manual wheelchair
I use a powered wheelchair
Sometimes
Always
Sometimes
Always
I use this wheelchair: I rely on someone else to push me in my wheelchair
Y
N
My wheelchair was recommended by
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

## C) Healthcare Professional/Social Services Officer Please Complete Either C1 Or C2 Below. C1) Details Of A Healthcare Professional C2) Details Of A Social Services Officer

Please give details below of a healthcare professional who knows about your mobility difficulties and who may be contacted for more information if necessary.

If there isn't a healthcare professional that we may contact but you have a Social Services Officer who knows about your mobility difficulties, please give their details.

Please let them know that they may be contacted.

Please let them know that they may be contacted.

Section 7 - COMMUNICATION
In case we need to contact you regarding your application, we will try to accommodate any communication needs that you have. Please tick if any of the following apply to you (please tick) I am hard of hearing I am profoundly/severely deaf I have a speech impairment 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.

Title (Mr/Mrs/Miss/Ms/Other) Name Address Postcode Telephone Relationship to applicant

## 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
Caribbean
Indian
Arab
British
White/Black Caribbean
Irish
African
Pakistani
White and Asian
Bangladeshi
Gypsy or Irish Traveller
White/Black African
Chinese
Any other White please write in above
Any other Black please write in above
Any other Mixed please write in above
Any other Asian please write in above
Any other 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

In order to provide you with this service your information will be disclosed to the London borough in which you reside. Your information will be used by London Councils and the London boroughs to process your application for a Taxicard, to promote and achieve equal opportunities and to improve the scheme (including to assess the services available to Taxicard users), and may also be used for other compatible purposes. Your personal information will not be disclosed to third parties unless it is legal to do so (e.g. to detect and prevent crime and protect public funds) Please note that all personal information you provide on this form or in support of your application, will be processed by London Councils and the London boroughs in compliance with the Data Protection Act 1998. 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 services to you.

## 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.
Y
N
I wish to be contacted about other services and initiatives.
Y
N
How did you hear about the London Taxicard Scheme?
Magazine
TV/Radio
Internet
Newspaper
Leaflet
Transport for All
Word of Mouth
Local Council Office
Other
(Please specify):

## Section 10 - Proof Of Identity And Residence You Must Provide One Example From Section 10A Below As Proof Of Identity (These Should Be Photocopies. Please Do Not Send Originals As These Cannot Be Returned To You) Section 10A

Copy of current Passport Copy of NHS Medical Card Copy of Birth Certificate (unless your name has changed) Copy of photocard or paper Driving Licence Copy of letter of entitlement to the Higher Rate Mobility Component of the Disability Living Allowance Copy of letter of entitlement to PIP (moving around activity)
You must provide ONE example from the Section 10b below as proof of residence
(These should be photocopies and be dated in the last 12 months. Please do not send originals as these cannot be returned to you)

## Section 10B

Copy of current Council Tax Bill/Letter/Payment Book Copy of current Council Housing Association Rent Book/Statement/Letter Copy of current Television Licence/exemption letter Copy of home or contents insurance documents Copy of tenancy agreement The items below marked with an * must be dated in the last 3 months Residential utility bill (excluding mobile phone bill) e.g. gas, electricity, phone, water *
Residential Personal Bank/Building Society/Credit Card statement or Bank letter * Copy of HM Revenue and Customs letter * Copy of letter of entitlement to benefits or pension * Copy of domiciliary care bill *
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.

PROOF OF ENTITLEMENT
PROOF OF IDENTITY AND RESIDENCE
ONE PASSPORT SIZED COLOUR PHOTOGRAPH

## Section 11 - Declaration Of Consent

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 authorise my healthcare professional, Social Services Officer and any contact person nominated on this form to disclose any necessary information for the purpose of assessing my eligibility for a Taxicard. 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.taxicard.org.uk 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:
London Councils Taxicard Section 59½ Southwark Street London SE1 0AL

## Section 11 - Declaration Of Consent

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 authorise my healthcare professional, Social Services Officer and any contact person nominated on this form to disclose any necessary information for the purpose of assessing my eligibility for a Taxicard. 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.taxicard.org.uk 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.