taxicard application form

TAXI-CARD APPLICATION FORM

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The Taxi-card scheme provides severely disabled (wheelchair dependent) residents of Plymouth with subsidised travel for their taxi journeys (not hospital appointments) within the Plymouth City boundary.

This section to be completed by / for applicant   [BLOCK CAPITALS PLEASE]

Applicants Full Name:     ___________________________________ Signature:_______________________

Address:    ____________________________________________________________________________________

______________________________ Post Code: ____________ Tel No: _____________

[Any change to the above details must be notified. We reserve the right to ask for proof of residence on change of address.]

This section to be completed by applicant’s Doctor

I confirm ______________________________ complies with ALL of the following Criteria.

delete as appropriate

1. Unable or virtually unable to walk. Or it would be dangerous to life if the applicant did walk. Yes / No

2. Dependent on a wheelchair at all times. Yes / No

3. Unable to transfer from a wheelchair to the front seat of a car. Yes / No

4. A resident of Plymouth. Yes / No

G.P.’s Signature: ___________________
Date: _____________________________

Surgery Stamp Please

The Applicant should bring this form in person to:- Plymouth Shopmobility & Community Transport, Mayflower Street East Car Park, Mayflower Street, Plymouth PL1 1QJ.
You will also need to bring:-

a]      Proof of residence in Plymouth [allowance book / utility bill etc.]

b]      A passport sized photograph for your Registration ID Card.

This section to be completed by member of Shopmobility & Community Transport Staff

Date of Registration . Proof of Identification
[Photocopy & attach if possible] .

Taxi-card Number . Signature .

Applicants Full Name: ___________________________________			Signature:_______________________
Address: ____________________________________________________________________________________
______________________________	Post Code:	____________		Tel No:	_____________

		delete as appropriate
1.	Unable or virtually unable to walk. Or it would be dangerous to life if the applicant did walk.	Yes	/	No
2.	Dependent on a wheelchair at all times.	Yes	/	No
3.	Unable to transfer from a wheelchair to the front seat of a car.	Yes	/	No
4.	A resident of Plymouth.	Yes	/	No

	a] Proof of residence in Plymouth [allowance book / utility bill etc.]
	b] A passport sized photograph for your Registration ID Card.

Date of Registration	.	Proof of Identification [Photocopy & attach if possible]	.
Taxi-card Number	.	Signature	.