Applicants for the Bus Pass Must Be Permanent Residents of Cardiff

PUBLIC TRANSPORT TRAVEL CONCESSION APPLICATION FOR DISABLED PERSONS FREE BUS PASS

Applicants for the bus pass must be permanent residents of Cardiff. How to apply :- If you

 do not require the assistance of another person to travel on a bus and  are registered blind / partially sighted; or  receive Disability Living Allowance, Mobility Component at the Higher Rate or War Pension please take this form in person, to the City Centre Hub, Ground Floor – Marland House, Central Square (next to the Bus Station), Cardiff, CF10 1EP, St Mellons Hub or Llanrumney Hub.

1/ appropriate evidence of disability 2/ proof of permanent residence in Cardiff e.g. recent council tax bIll or utility bill i.e. gas, water, telephone or electric bill, . Photocopies and statements/bills printed from the internet will not be accepted.

There will be no need to supply a photograph if you apply in person.

Alternatively you may apply by post to the above address. Please mark the envelope 'Travel Pass’. Postal applications must include a recent passport-sized photograph of the applicant, proof of permanent residence in Cardiff and supporting evidence of disability. The County Council will take care of documents provided, but cannot accept responsibility for applications lost in transit.

If you

 require a companion to help you travel or  do not qualify under the criteria above (i.e. if you are not registered blind / partially sighted, or are not in receipt of Disability Living Allowance with the Mobility Component at the Higher Rate) you will need to have your application form assessed by your General Practitioner (see Part B and Part C if you require a companion). Your General Practitioner may charge you for this service. Once the form has been certified by your doctor please apply as detailed above.

If you require further information please contact C2C on 029 2087 2087

Declaration Information provided by you on this form will be used to determine your entitlement to a concessionary bus pass and for administering the bus pass scheme. The Council is under a duty to protect the public funds it administers, and to this end may also use the information you have provided on this form for the prevention and detection of fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. Further information about this is available on our website at www.cardiff.gov.uk/fraud or you may contact the Information Manager, CY4B County Hall, Cardiff CF10 4UW .

4.HWM.PT.F42 Date Issue 13 Process Owner Page 1 of 4 11/02/2014 John Gibson PUBLIC TRANSPORT TRAVEL CONCESSION APPLICATION FOR DISABLED PERSONS FREE BUS PASS

PART A To be completed by applicant Title (Mr, Mrs, Miss, Ms)………. Surname…………………………………………………………………

First Names ………………………………………………………………….………..……………….…..…

Permanent Address (House no. / name and road) ………………………………………………….……

District..………………………………………….… Cardiff Post Code….…………………..

Date of Birth ...... Telephone Number……………………..……………..

There is no need for this form to be certified by a doctor if you do not need a companion to travel and are able to provide evidence of disability as Attach colour described on page 1. passport sized Neither a standard bus pass nor a Companion Pass is available to a child below photo here if the age at which it is necessary to pay a fare for travel (five years of age). applying by post I do not require a companion to travel. 45mm X 35mm I am registered blind / partially sighted I receive Disability Living Allowance, Mobility Component at the Higher Rate I enclose evidence of disability

If you do not qualify under the criteria above (i.e. if you are not registered blind / partially sighted, or are not in receipt of Disability Living Allowance, Mobility Component at the Higher Rate) your application will need to be certified by your General Practitioner see Part B.

I do not require a companion to travel. Part B of my application has been certified by my General

Practitioner

If you have severe disability and require a companion in order to travel on a bus please see part C of this form.

I require a companion to travel. Parts B and C of my application have been certified by my General Practitioner Any doctor's fee payable for completion of the form is the responsibility of the applicant. I apply for the issue of a Disabled Persons Fare Concession Permit for my personal use and agree to abide by the conditions of issue.

Signed ……………………………………………………. Date ………………………….

Office use only Date Evidence Data entered by Certified by Ref. No. 4.HWM.PT.F42 Date Issue 13 Process Owner Page 2 of 4 11/02/2014 John Gibson PUBLIC TRANSPORT TRAVEL CONCESSION APPLICATION FOR DISABLED PERSONS FREE BUS PASS

PART B To be completed by applicant’s GP MEDICAL CERTIFICATION THIS FORM CANNOT BE ACCEPTED WITHOUT THE PHYSICIAN'S OFFICIAL STAMP l hereby certify that ………………………………………………………………………(enter full name) qualifies for the disabled persons’ travel concession as he/she complies with the criterion/criteria as indicated below: Signature of Physician ……………………………… Date ……………………………………

Name of Physician ………………………………….. Physician’s stamp BLOCK LETTERS

A has a disability or injury which in the opinion of the Council seriously impairs his/her ability to walk. The walking disability must have substantial and long-term adverse effect on the applicant’s ability to walk more than 100m without stopping, or without severe discomfort or help from another person. The disability must be permanent (or lasted 12 months or likely to last 12 months). Guidance from the Welsh Assembly Government suggests that the degree of disablement should not fall short of that needed to qualify for the Higher Rate of Mobility Component of Disability Living Allowance. An applicant receiving Lower Rate DLA would not qualify for a pass.

B would be refused a driving licence or has had a driving licence revoked on medical grounds. Persons who, on medical grounds, would be refused a driving licence or have had their driving licence revoked and who are over 17 years of age. People who persistently misuse drugs or alcohol are not covered under this Scheme and not entitled to concessionary travel.

C is without the use of both arms Persons who do not have arms or have long-term inability as to the use of both arms. These include upper limb double amputees and those with congenital absence of both upper limbs.

is without speech D Persons considered to be without speech are those who are unable to make clear basic oral requests (e.g. to ask for a particular destination or fare) - Unable to ask specific questions to clarify instructions e.g. "Does this bus go to the High Street ?" This does not include persons whose speech may be slow or difficult to understand because, for example, of a stammer.

has a learning disability E Persons with a learning disability, that is a state of arrested development which includes significant impairment of intelligence and social functioning. The person has a reduced ability to understand new or complex information, a difficulty in learning new skills, and may not be able to cope independently . These disabilities must have started before adulthood and have a lasting effect on development.

F is blind or partially sighted

G is profoundly or severely deaf

4.HWM.PT.F42 Date Issue 13 Process Owner Page 3 of 4 11/02/2014 John Gibson PUBLIC TRANSPORT TRAVEL CONCESSION APPLICATION FOR DISABLED PERSONS FREE BUS PASS

This section must be completed by a General Practitioner or a Consultant. PART C MEDICAL CERTIFICATION FOR A COMPANION BUS PASS THIS FORM CANNOT BE ACCEPTED WITHOUT THE PHYSICIAN'S OFFICIAL STAMP

 A companion pass is available to people who qualify for the standard bus pass as a result of disability and who are so severely disabled that it would be impossible for them to make a bus journey without assistance.  The companion concession is provided to enable escorted travel by people with disabilities that would not otherwise be possible, because they, or other passengers, would be exposed to risk if they were to travel alone  Neither a standard bus pass nor a Companion Pass is available to a child below the age at which it is necessary to pay a fare for travel (five years of age). The cost of accompanied travel for very young children who cannot travel alone, is a parental responsibility. Funding of travel for the parents or other people responsible for the care of children with disabilities below the age of 5 years is not therefore part of the companion pass concession. l hereby certify that the person below is disabled to such an extent that they are unable to use public transport without assistance and require a companion

Please state the criteria as indicated in part B eg A Full name of applicant ………………………………………………………………………………… Please provide brief details of the applicant’s disability with confirmation of why the applicant requires a companion to travel. The Council will not be able to consider applications without this information.

SIGNATURE OF PHYSICIAN......

Name of Physician ………………………………….. PHYSICIAN'S STAMP

BLOCK LETTERS Date ......

4.HWM.PT.F42 Date Issue 13 Process Owner Page 4 of 4 11/02/2014 John Gibson