Concessionary Bus Pass
I want to apply for
a Disability-Related
Concessionary Bus Pass
The text in this document is available in full at
www.gloucestershire.gov.uk/buspass
You need to fill in this form
Your Free Bus Travel Pack has notes to help you.
Visit:
www.gloucestershire.gov.uk/buspass
for a printable version
Email:
[email protected]
Call:
Concessionary bus pass helpline 01452 426265
STEP 1
Please tell us about you
Please write in BLOCK CAPITALS. You must fill in boxes
marked*
What are you called * Mr
Mrs
Ms
Miss
Dr
Other (please specify)
Your first name*
Your middle name(s)
Your surname*
Your telephone number
Are you? * Male
Female
Your date of birth*
Your email address
How would you like us to get in touch with you if we need
to ask you something?
Telephone
Email
Post
It is quicker for us to call you by telephone or email you.
Your Full Address*
Your Postcode*
If you have a bus pass now please write the
long number on the front in the space below
633597
STEP 2
Proof of your disability
We need to know about your disability. Proof of disability are
listed below. Do you have one of them?
Please tick the proof you will be providing.
I have a valid Blue Badge.
Please write down your blue badge number as shown on the front left of your badge in this box.
(If you give us your blue badge number you are allowing
us to check your application against information you have
already given to get your Blue Badge)
If you do not have a valid blue badge number you can give
us a document that must be an original and less than one
year old.
I have a war pensioner’s mobility supplement award letter
I have a letter awarding the higher rate mobility component of the Disability Living Allowance or Personal Independence Payment (PIP) with a score of at least 8 points on account of inability to walk, or to communicate orally without support.
I have a letter from the Department of Transport
It states that under Part III of the Road Traffic Act 1988 I have been refused or had my driving licence withdrawn pursuant to section 92 of
that Act
If you have ticked a box above you can go to Step 4
If you have not ticked a box go to Step 3
STEP 3
Proof of your disability
If you can’t tick one of the boxes from the list in Step 2
you need to fill out a D5 Form. This form says “I would
like to apply for a concessionary bus pass because I have
a Learning Disability that makes it hard for me to travel
without help”.
You can get this form in Your Bus Travel Pack. If
you need help please go to the start of this form.
The form must be completed and signed by your
medical specialist or professional support worker or
recognised specialist advisor. They may charge you
for this service.
Hospital Consultant, Doctor or Specialist Nurse
Your Social Worker
Your Support Worker
A specialist school or college for pupils / students
with a severe learning disability
Specialist organisations eg: Gloucestershire Deaf
Association
A letter or certificate from your doctor will not be
accepted as evidence.
STEP 4
Proof of where you live
You must provide us with proof of where you live.
You can show us one item from the list below. It must be
an original and less than one year old.
Please tick only one from the list below that you will be
providing as proof of where you live.
Bank Statement
Driving Licence
NHS medical card
Utility bill
Optical / medical Benefit book / letter
prescription counterfoil
Do you need a Companion Bus
Pass?
If you are unable to travel alone due to your disability you
may be eligible for a companion bus pass.
I need a Companion Bus Pass - Go to Step 5
I can travel on my own - Go to Step 6
STEP 5
Concessionary Companion Pass
This will allow you to be accompanied by any person over
16 years of age, free of charge.
To qualify for a Companion Bus Pass you need to ask
your doctor to complete the C1 form - Application for
Concessionary Companion Pass.
If you qualify you will get a companion pass based on the
severity of your disability, not your age.
Your C1 form must be provided in addition to your proof
of disability.
You can get this form in Your Free Bus Travel Pack. If you need help please go to the start of this form.
I wish to apply for a Companion Bus Pass and will provide a C1 form.
STEP 6
Declaration
We need you to be sure that what you have told us is right.
I declare that I am eligible to apply for a disability related
concessionary bus pass. The address I have given is my
sole or principle residence and is within the county of
Gloucestershire.
If I am given a concessionary bus pass I will obey
Gloucestershire County Council’s rules of use. I understand
they may be changed from time to time.
I agree that if I have applied for and receive tokens or
vouchers under a scheme run by the district council, I
cannot have a concessionary bus pass for the year for
which the tokens or voucher apply.
I authorise Gloucestershire County Council to use the
information I have provided to make enquiries necessary to
verify entitlement and detect fraud.
This may include sharing this information with other
organisations that audit or administer public funds.
I accept that my records, including proof of eligibility, will be
retained securely by computer database for the purposes
of administering the Gloucestershire County Council
Concessionary Bus Pass Scheme and to make sure the
law is upheld.
If I move away from the county of Gloucestershire
permanently I confirm that I will return my concessionary
bus pass.
By signing this form I confirm that I have filled it in honestly
and correctly.
Your Name
Your Signature
Today’s Date
What you should do with this form
There are two ways to submit your application form.
I want to post my application - Go to Step 7.
I want to take my application to the Library - Go
to Step 8.
Please note that you cannot apply by post and have your
photograph taken at a library.
STEP 7
Apply by post
We will need a colour photo of you.
If you are applying by post, please send
us a recent, colour, passport-sized
photograph. Please fix the photograph
to the space.
If you go to a library, a member of staff
at the library will take your photograph
for you.
Post this form along with the things we need for your
application to:
The Blue Badge & Concessionary Bus Pass Team
Sandford Park House
39-41 London Road
Cheltenham
Glos
GL52 6XJ
If you are giving us items that are either valuable or difficult
to replace as part of your application please send them by
recorded delivery post.
We will send documents you have given us back to you as
soon as we have dealt with your application.
STEP 8
Apply at a library
You can take your application and things you need to prove
your disability and where you live to any of the Libraries
listed below. Library staff can take your photograph.
You can call 01452 426265 to visit at a time when the
library will be open. You will be put through to the library of
your choice.
Which Library can I go to with my application forms?
Cheltenham Borough
•Cheltenham,
•Charlton Kings,
•Up Hatherley,
•Hesters Way,
•Prestbury
Gloucester City
•Gloucester,
•Hucclecote,
•Longlevens,
•Matson,
•Quedgeley,
•Tuffley
Stroud
•Stroud,
•Dursley,
•Nailsworth,
•Stonehouse,
•Wotton-under-Edge
one stop shop
Cotswold
•Cirencester,
•Chipping Campden,
•Fairford,
•Stow-on-the-Wold,
•Tetbury
Forest of Dean
•Coleford,
•Cinderford,
•Lydney,
•Newent
Tewkesbury Borough
•Tewkesbury,
•Bishop’s Cleeve,
•Winchcombe,
•Churchdown
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