How to complete this form
How and where to send the form
Notes for applicant
Make sure you enclose your passport photograph
with your application form. Place inside an
envelope, seal securely and post to:
This card is only available to West Sussex residents aged
5-19 and in school or full-time further education.
An application fee of £50.00 applies unless your family
meets certain low income criteria (see below).
You will also need to provide ONE passport photograph
(please do not attach this to the form) and ask your
teacher or tutor to complete PART B of the form.
How long will my card be valid for?
If you are of compulsory school age, your card will be
valid for three years or until you reach the end of Year
11, whichever is sooner.
If you are in sixth form or college, your card is valid for
one academic year only.
When/where will I receive my card?
Your card will be sent to you in approximately 4-6 weeks
from when we receive your completed form. This will be
sent to your home address, unless you are in further
education in which case the card will be sent to your
school or college for you to collect.
Payment information
l
Payment can be made by cheque, Postal Order,
or any of the following credit/debit cards: JCB,
Maestro, Mastercard, Solo, Visa and VisaDebit.
l
Please make cheques and Postal Orders payable
to West Sussex County Council.
l
To pay by credit/debit card, please call 01243
756689 - you will be given a unique payment
reference number to enter into the space provided
in Part C before sending your application.
You are exempt from payment if:
l
You receive free school meals.
l
Your family is assessed as being on a low income.
You will need to complete a ‘Low Income Exemption
Form’ and provide evidence of the benefit your family
receives. Please visit www.your3in1.co.uk for a form
and further information, or call 01243 777330.
Your3in1 CitizenCard Scheme
West Sussex County Council
Communities and Infrastructure
County Hall , West Street
Chichester, West Sussex PO19 1RQ.
YOUR 3in1 CITIZENCARD CONDITIONS AND DISCLAIMER
If you wish to apply for Your3in1 CitizenCard you must:- complete the Your3in1
CitizenCard application form; enclose one passport photograph (please print your
name on the back of the photograph) as instructed on the form l As soon as you
receive the Your3in1 CitizenCard you must check the details are correct. If they
are not correct you must return it immediately l You must tell us immediately if
the card is lost, stolen or if you believe that someone else is using the Your3in1
CitizenCard l The Your3in1 CitizenCard may only be used by you and you must not
change the card in any way l If you misuse the Your3in1 CitizenCard you may be
committing a criminal offence l The Your3in1 CitizenCard may be confiscated by a
Bus Operator for: abuse of the service being provided, including misbehaviour,
abusive language and bullying; or any breach of these conditions l We may issue
a replacement Your3in1 CitizenCard if it is lost, stolen, or damaged for a fee of £12.
Replacement cards can be requested by emailing [email protected] or
calling 01243 777330 l The Council will not be liable if the Your3in1 CitizenCard is not
accepted as proof of your age or identification, or if you are unable to use it because a
bus has been cancelled, is late, or there are no seats, or standing room l Personal data
supplied in your application form remains confidential and is never passed on to third
parties l Completed application forms should be sent to the above address.
3in1
travel, shop and
play the 3in1 way
cheaper bus fares | discounts | proof of age
3in1
Application form for 5-19 year olds
WSCC does not support or recommend the products or services advertised nor
the organisations advertising/participating in this scheme. Cardholders and their
parents should satisfy themselves on the suitability of any of these products or
services and on the nature and standing of these organisations.
TRANSPORT CO-ORDINATION GROUP CONDITIONS OF THE CONCESSIONARY
FARES CARD:
Parents and children will be responsible for ensuring that behaviour on the
vehicle is acceptable and complies with any code of conduct issued by the school
and the County Council. Unacceptable behaviour may result in the withdrawal
of the concessionary card. Misuse of the card may result in the withdrawal of the
concessionary fare. The use of the card does not guarantee the availability of a
bus service or a seat on an existing service.
Information contained in this form is personal data which will be held on a computer
and is, therefore, subject to the Data Protection Act 1998. This authority is under a duty
to protect the public funds it administers, and to this end may 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. For further information, see www.westsussex.gov.uk/nfi
If you would like a copy of this
leaflet in another format, for
example, audio, braille, large
print or in another language,
please call 01243 777330.
WS052(1) 07.11 Graphic Design
www.westsussex.gov.uk
For more info visit
www.your3in1.co.uk
For more info visit
3in1 www.your3in1.co.uk
in association with
PART A - APPLICANT TO COMPLETE | Please use CAPITAL LETTERS, black ink, one letter or space per box
First name Surname
Male
Female
3in1
Date of birth
D D M M Y Y Y Y Email*
* Required to be eligible for CitizenCard LEALTA discounts
Address
County
Post Code
(N.B. Don’t forget to print
your name on the back of
the passport photograph)
Home tel.no. (inc. code)
Mobile*
* Required to be eligible for CitizenCard LEALTA discounts
If you will be attending a NEW school or college from September, please write the school/
college name here
Existing method of school transport
bike bus
car/car share
coach
taxi
train
walk
Signature of applicant or applicant’s parent/guardian
OFFICIAL
USE
PASSPORT
PHOTO ONLY
7
We may want to use the contact details on your application form to send you more information. Tick here if you do not want us to do that
PART B - REFEREE TO COMPLETE | A referee must be your school teacher, course tutor or lecturer
Referee name
Name and address of School/College
Signature
I certify that the photograph provided is a true likeness to the above named
applicant. Please also sign the REVERSE of the applicant’s photograph.
7
Date
D D M M Y Y Y Y
PART C - PAYMENT DETAILS | Please see reverse for further information
Please tick ONE of the following:
I am exempt from payment because:
I enclose a cheque or Postal Order for £50.00.
I receive free school meals.
I have paid £50.00 by telephone with my credit/debit card and my payment reference number is
My family is assessed as low income and I enclose
a Low Income Exemption Form and appropriate
photocopy evidence.
PART D - TRANSPORT CO-ORDINATION GROUP | OFFICIAL USE ONLY
Reference number
Official stamp
Initial of processor
Expiry date
D D M M Y Y Y Y
Please see reverse for further instructions on how to complete the form - should you have any
questions please call 01243 777330.