Smartcities card application form Southampton City Council ‘smart’ card that can be your bus pass, donor card, library card, leisure card and Itchen Bridge Toll card. Smartcities Form valid fro Septemb m er 2012 Apply online www.southampton.gov.uk/smartcities 1. Welcome 2. Choose your services The Smartcities card is a ‘smart’ card that can be used for a number of different services. Simply choose what you would like to go on your card from the list opposite, fill in the appropriate sections and apply at one of the venues given on page 15. Which services would you like to go onto your Smartcities card? Personal details *Gender M Senior Citizens please complete section 3 Itchen Toll Bridge If you would like to use your Smartcities card or concessionary bus pass to pay toll charges on the Itchen Toll Bridge please complete section 5 *Title Mrs Concessionary bus pass for residents of the City of Southampton Eligible disabled residents please complete section 4 Please complete in block capitals in black/blue ink. *Mandatory fields. Mr Please tick the boxes below and complete the relevant sections. Miss F Master Ms *Date of birth Other, please state / / Age *First name(s) *Last name National Insurance Number *Which town/city were you born in (Should you need to contact us, we will use this to verify your identity)? Get Active - Do more for less! For residents applying for the discount scheme please complete section 6* PASS Proof of age - The National Proof of Age Standards Scheme. If you need to be able to prove your age please follow the instructions in section 7 NHS Organ Donor Register If you would like to join the register please complete section 8 Library card number - Tick here if you would like to use your Smartcities card in any Southampton City library. If you already have a Library card please enter your number here and we will transfer your membership. *Address Leisure Venues card - Please indicate if you would like to use your card in the Southampton leisure venues.* If you already have an existing Leisure Venues card please enter your number here. *Postcode Telephone (inc area code) Please provide at least one of the following if possible: Existing Smartcities card - If you already have a Smartcities card or *Daytime No.Mobile Bus Pass issued by Southampton City Council, please enter your account number here. **Email ** If you want to manage your Itchen Bridge account online, you must provide an email address. 2 * Participating venues include: The Quays Swimming & Diving Complex, Bitterne and Chamberlayne leisure centres, Southampton City Golf Course. 3 3. Concessionary bus pass 4. Concessionary bus pass For Southampton residents of pensionable age For eligible disabled Southampton residents I am of pensionable age. The date when a woman becomes eligible for her state pension is also the date when men and women become eligible for their concessionary bus passes. Please see one of the following: • Bus pass age qualification leaflet available in Southampton libraries, local housing offices or in Gateway at One Guildhall Square • www.smartcities.co.uk • Or telephone Smartcities on: 023 8083 3008. Companion Pass* If you are unable to travel alone on a bus at any time due to medical reasons and require a companion pass, you will need to provide two documents. The first being one of the following: A letter from the Department for Work and Pensions confirming that you are receiving the higher rate of the care or mobility component of Disability Living Allowance or Attendance Allowance. An official letter confirming that you are in receipt of war pensioner’s mobility supplement. A registration card stating that you are registered as blind, partially sighted, deaf or without speech. And also A letter from a medical practitioner confirming that you are unable to travel alone on a bus for medical reasons. Applicants who are eligible disabled and under pensionable age can apply for an English National Concessionary* bus pass by completing this section. (Please note that in addition to the qualifying evidence required in this section we also require the documents listed in the checklist in section 11). I am blind and provide my registration card. I am partially sighted and provide my registration card or my Certification of Vision Impairment (CVI). I am profoundly or severely deaf and provide my registration card. I am without speech and provide my registration card. I am in receipt of the higher rate of the mobility component of Disability Living Allowance and provide a recent letter from the Department for Work and Pensions confirming this. I have been refused a driving licence on medical grounds and provide a recent letter from the DVLA confirming this. I have a learning disability and I am registered with Southampton Day Services or Southampton Learning Disabilities team and I provide a letter to confirm this. I am in receipt of War Pensioner’s Mobility Supplement and provide my award letter from the Service Personnel and Veterans Agency. I enclose a completed 09MQ form, signed and stamped by a medical practitioner, confirming my eligibility. Proof of eligibility required for a Local Southampton Bus Pass* For eligible disabled Southampton residents I am in receipt of the lower rate of the mobility component or any rate of the care component of Disability Living Allowance and provide a recent letter from the Department for Work and Pensions confirming this. The Local bus pass entitles you to free off-peak local bus travel within the Southampton City Council boundary.* Please see section 3 if you require a companion pass. 4 *terms and conditions apply *terms and conditions apply 5 5. Itchen Toll Bridge Concession and Payments Southampton Residents Eligible Disabled Persons A concession is available to residents of the City of Southampton. The concession applies to cars and light vans in class 2 vehicles only.* Eligible disabled non-residents living outside of the City of Southampton wishing to apply for a Smartcities card, enabling them to pass through the toll system easily and travel free in their class 2 vehicles, will need to be in receipt of the Higher Rate of the Mobility component of Disability Living Allowance and provide a photocopy of both sides of their Blue Badge. Applying for a Smartcities card will allow you to make prepayments on your Itchen Bridge account and have the residents’ concessionary toll deducted at the time of crossing. I am a resident of the City of Southampton i.e. I live in a property where council tax is paid to Southampton City Council. Eligible Disabled Southampton Residents Eligible disabled residents wishing to apply for a Smartcities card or concessionary bus pass enabling them to pass through the toll system easily and travel free in their class 2 vehicles will need to be in receipt of the Higher Rate of the Mobility component of Disability Living Allowance and provide a photocopy of both sides of their Blue Badge. □ I am an eligible disabled resident living within the Southampton City Council boundary. I provide a letter from the Department for Work and Pensions confirming that I am in receipt of the Higher Rate of the Mobility component of Disability Living Allowance. and □ I attach a photocopy of both sides of my Blue Badge. *Class 2 vehicles are cars and light vans with a height measured at the first axle of no more than 1.33 metres 6 I am an eligible disabled applicant living outside of the Southampton City Council boundary. I provide a letter from the Department for Work and Pensions confirming that I am in receipt of the Higher Rate of the Mobility component of Disability Living Allowance. and I attach a photocopy of both sides of my Blue Badge. Please note that only residents of Southampton City Council can be issued with a concessionary bus pass which can also be used on the Itchen Bridge. Non-residents will be issued with a different card for use on the Bridge. Non-residents: There are no concessions for non-residents. However, the Smartcities card will enable you to make prepayments on your Itchen Bridge account and have the toll deducted on each crossing removing the need to have the exact change. I live outside of the Southampton City boundary and do not pay council tax to Southampton City Council. Note: If you are a local Southampton business and would like to apply for a Smartcities card, please request a commercial concession application form by telephoning 023 8083 3008, or visit our website at www.smartcities.co.uk 7 6. Get Active The Get Active subscription* entitles you to a discounted rate on a range of non-instructed activities at off-peak times at the following Southampton leisure venues: Active Nation venues: The Quays Swimming & Diving Complex, Bitterne and Chamberlayne Leisure Centres, Southampton Outdoor Sports Centre. For more details see www.activenation.org.uk Mytime Active venue: Southampton City Golf Course. For more details see www.mytimegolf.co.uk Discounted activities include*: Swimming, use of fitness suites, badminton, tennis court hire, 9 holes of golf, new age curling, bowls and other activities. Allotments - The Get Active subscription* will also give you a 50% discount from your rental on your allotment plot if you are not already receiving a discount. For a full list of discounted activities please visit our website: www.smartcities.co.uk and click on Get Active on the left hand side. When applying for Get Active, please be aware that you will need to renew your membership every 12 months in Gateway at One Guildhall Square and evidence of entitlement will need to be produced at the time of renewal. Renewals will be activated remotely on your existing Smartcities card. Please indicate which benefit you are receiving on the list on page 9 and provide evidence of your entitlement. Housing Benefits Housing Benefits - Notification letter on headed paper. Income Support/Guarantee Pension Credit Correspondence from DWP or Job Centre. Council Tax Main Benefit Council tax bill, letter from council tax benefit. Job Seekers Income Based Award letter, stamped letter from DWP or Job Centre. Incapacity Benefit /ESA correspondence from DWP or Job Centre. Severe Disablement Allowance ** Correspondence from DWP. Disability Living Allowance/Attendance Allowance ** Correspondence from DWP. Unwaged spouse/partner Proof of relationship with the main applicant receiving benefit e.g. marriage certificate, official documentation. Unwaged Child Under 18 Proof of relationship with the main applicant receiving benefit e.g. birth certificate. ** These benefits are for individual claimants only. Therefore partners/children may not be eligible for Get Active. Please note that the Get Active subscription is only available to residents of the City of Southampton. *Please check with the venues for off-peak times. Terms and conditions apply. 8 9 7. PASS - Proof of age The Proof of Age Standards Scheme (PASS) is a UK-wide accredited proof of age scheme, backed by the British Retail Consortium, the Home Office, Trading Standards Institute, the Association of Chief Police Officers (ACPO) and Southampton City Council to help retailers stay within the law when selling age-restricted goods. Southampton City Council and the applicant’s verifier are obliged to certify the holder’s date of birth and identity. Applicants applying for PASS must supply Smartcities with a recent passport quality photograph showing a clear likeness of the applicants head, shoulders and face. Applicants may not wear a hat or dark glasses. You will need to take your photograph, an original form of identity e.g. passport, birth certificate or photo style driving licence) and a photocopy of the identity document to your verifier. The verifier will need to certify the back of the passport photograph as well as sign and date the photocopy of your personal identification document and complete, sign and stamp section 6 in the application form. The verifier must sign and date the back of the photograph confirming that this is a true likeness of the applicant and complete the following table. Please sign the back of the passport sized photograph Verifier please complete Title & first name Official stamp: Surname Occupation & professional title Work address including postcode Full work phone number (including area code) no home or mobile numbers are acceptable. To be completed by the verifier To be able to act as a verifier, you must be over the age of 25 and be one of the following: Careers/connexions adviser or librarian, dentist, doctor, optician, pharmacist or vet, elected local authority councillor, judge, sheriff, magistrate, barrister, solicitor, bank manager or accountant, MP, MEP, AMW, AMNI, or MSP, minister or other official of religion, police officer or police civilian staff, trading standards officer or staff, teacher, tutor or lecturer, established civil servant. Verifiers may not be close relatives of the applicant or have Guardian, Foster Parent nor Carer status in relation to the applicant. If the verifier knows the applicant sufficiently to verify their identity and age, passports, birth certificates or photo style driving licences can be provided as proof of identity. • I have seen the applicant’s passport, birth certificate, photo style driving licence (delete as appropriate) and have signed and dated the photocopy and • I have verified the back of the photograph as shown above Declaration: I confirm that the details the applicant has given are true as far as I know and that the photograph represents a true likeness of the applicant. Verifier signatureDate In the case that the verifier does not know the applicant at all, only passports or photo style driving licences are accepted as proof of identity. 10 Any verifying person who knowingly attempts to aid a fraudulent application by giving incorrect or false information may be liable for prosecution and the application will not be valid. 11 8. Organ donation 9. Future initiatives, events and discounts Organ transplants are one of the most miraculous achievements of modern medicine, but they depend entirely on the generosity of donors and their families who are willing to make this life-saving gift to others. One donor can save or improve the lives of up to nine people and restore the sight of two others. We hope to run a number of new initiatives in the future. Please indicate anything that might be of interest to you and we will let you know if and when they are happening. Thousands of people’s lives are saved each year by the generosity of organ donors. However, right now, more than 10,000 people in the UK need a transplant and of these 1,000 will die waiting, as there are not enough organs available. By signing up to the NHS Organ Donor Register you are joining 19 million kind-hearted people who have registered their wish to be a donor. Don’t forget to let your family and friends know about your wishes. Talk to them now so they know exactly what you want if the time ever comes. Leisure centre offers/promotions Events and activities at libraries City events (such as the Boat Show and events on the Common and parks) Travel related initiatives (such as peak discounts on bus or reduced entrance fees at venues reachable by bus) Even if you currently carry a donor card, it is important to register your wishes. If you want to find out more call the Organ Donor Line on 0300 123 23 23 or visit www.organdonation.nhs.uk. New services (which you can access with your card) If you wish to amend or withdraw your record from the NHS Organ Donor Register you can do so by calling the Organ Donor Line number above. High Street discounts My wishes Contacting You I would like to donate: (Please tick the boxes that apply) Please let us know the best way to contact you about the services on your card by indicating all ways in which you are happy to be contacted. A. Any of my organs or tissue Contact by: (Please tick the boxes that apply) or Email B. My kidneys liver heart eyes lungspancreas for transplantation after my death. 12 Data Protection Assurance Completion of section 8 is for the sole purpose of recording your wishes on the NHS Organ Donor Register. All data processed by NHS Blood and Transplant (NHSBT) is in accordance with the provisions of the Data Protection Act 1998. Your details will only be used for administration purposes by NHSBT staff or agents and will not be released to any third party without your written consent. The data you provide may be processed on our behalf in a country not normally covered by EU data protection law. If so, we will ensure that the data will be protected in accordance with EU requirements. Home phone Mobile phone By Text (on mobile phone) Letter 13 10. Complete and sign 11. Application check list My ethnic origin For all applications please include: • A recent colour passport photograph of yourself on a light background. • Proof of your address in your own name not older than 3 months (e.g. a utility bill, bank statement or any other official letter). • Proof of your personal identification containing your date of birth (e.g. a passport, driving licence or birth certificate if in your current name). Additional documents are also required for the following services: • Concessionary bus pass for residents under pensionable age - one proof of qualification as stated in section 4. • Itchen Bridge Disabled Concession - eligible residents and non-residents need to provide a Disability Living Allowance award letter stating that they are in receipt of the higher rate of the mobility component and provide a photocopy of both sides of their Blue Badge. • The Get Active subscription - proof of being in receipt of one of the benefits listed on page 9. • PASS Proof of Age applications - a copy of your personal identification document which has been signed and dated by your verifier and your verified photograph must be attached to the application form. White: British (Please tick the boxes that apply) Irish Other Mixed: White/Black Caribbean White/Black African Other Asian or Asian British: Indian Bangladeshi White/Asian Pakistani Other Black or Black British: Caribbean Other ethnic categories: Chinese African Other Other Not stated By signing this form you are agreeing to the current terms and conditions of the services you have selected and declaring that the information given is correct. Applicants under the age of 14 will need a parent/guardian to countersign the form. For further information, please visit www.smartcities.co.uk, telephone the Smartcities team on 023 8083 3008, or email [email protected]. Signature Signature of parent/guardian Please apply in person at any library or local housing office in Southampton or in Gateway in One Guildhall Square. Applications by post are not accepted. Copies of documents confirming eligibility need to be taken and attached to the application form. (under 14’s only) Office use only LocationReceived by Date received Date Date The ID document seen The proof of address seen Image cap number 14 Get Active application only: Benefit seen (circle) IS JSI/ESA GPC HB CT SDA IB DLA SCC Proof of age (circle) DL BC PAS Proof of relationship with main applicant (circle) MC DL DOC PASS applications only: Photograph endorsed on back Yes No Verifying person section completed Yes No Copy of ID document signed by the verifyer Yes No 15 Terms & conditions • The card must be used according to the terms and conditions laid down by the individual services offered on the card. • Smartcities means Smartcities, One Guildhall Square, Southampton, SO14 7FP. • Any individual over the age of 3 years can apply for a Smartcities card. Only one Smartcities card will be issued to an individual. • Only the cardholder may take advantage of the Smartcities card. It is not transferable. • The card will need to be produced whenever the cardholder wishes to take advantage of the services offered by Smartcities. • All lost and stolen cards must be reported within 72 hours to Smartcities on 023 8083 3008. Cards that are lost, stolen or damaged will be replaced after an administration fee is received, unless a police crime reference number is supplied (only one card per year will be reissued free of charge when a crime reference number is provided). • Smartcities will pass information to authorities in the interests of the detection of fraud and other illegal purposes. This will be done in accordance with the Data Protection Act 1998. • When a cardholder changes their name, a new card will be created after fulfilling authentication needs and there will be no charge. • Smartcities must be notified immediately of any change of address or circumstance. • It is the responsibility of the cardholder to provide Smartcities with correct information. • Smartcities reserve the right to withdraw or amend the Smartcities card with reasonable notice/or no notice. • Smartcities will not be liable for any mistakes and/or omissions made by the cardholder at any time. • Periodically we will contact you to ensure that the information we hold is up to date. • The Smartcities card remains the property of Southampton City Council and must be returned upon request. • Smartcities accepts no responsibility for the loss or damage to original documents submitted for use in the application process. Get Active • Anyone aged 3 years or over may apply for a Get Active subscription. Applicants must live within the Southampton City Council boundary. • The Smartcities card must be produced with a 16 valid Get Active subscription to obtain a reduced rate, otherwise the full charges must be paid. • Get Active subscribers may not book in advance for reduced rate sessions at participating Southampton leisure venues. • To obtain Get Active rates for individual court hire all players must be in possession of a Get Active subscription. • The Get Active subscription is valid at off peak times. At all other times the standard rate will be applicable. It does not exist for all services e.g. club/group bookings and team sports are excluded. • Applicants receiving a Get Active subscription must notify Smartcities immediately if their circumstances, or those of their dependants change, or if they cease to qualify for any other reason. • If applying for a Get Active subscription you will need to renew every 12 months, and all relevant documentation must be shown at time of renewal. • Southampton City Council reserves the right to amend or withdraw all or part of the benefits at any time. • Use of fitness suites is subject to an induction. • Carers accompanying a person who qualifies under the disabled category are entitled to free access to assist the person with the disability. It is the carer’s responsibility to support the individual whilst undertaking the activity. PASS - Proof of age • Any authorising person who knowingly attempts to aid a fraudulent application may be liable for prosecution. • The information that has been supplied to us will be checked for authenticity. Concessionary bus pass • The concessionary bus pass can only be used by the cardholder, as per the concessionary scheme administered by Southampton City Council. The cardholder may be accompanied by a companion in accordance with the conditions of the scheme. For full terms and conditions see www.smartcities.co.uk. • Fraudulent use of this pass will result in its withdrawal and may lead to prosecution. • Passengers using this pass will be carried as per the conditions of carriage of the bus company on which they are travelling. • The concessionary bus pass is only valid for off- peak travel except in the case of Blind persons, as described below. National off-peak is defined as between 9.30am-11pm Monday to Friday, and at any time at weekends and bank holidays. Local off-peak travel is defined as between 9am-11.59pm and any time at weekends and bank holidays. • Local off-peak times may be subject to change. • Blind persons are permitted to travel free at any time; however, when travelling before 9.30am they can only travel free on a bus service which starts in Southampton on a direct route, on production of their concessionary bus pass featuring a green triangle. • A local Smartcities (non-English National Concessionary) bus pass is only for use within the Southampton City Council boundary. • Concessionary bus cardholders must notify the Smartcities bureau immediately if their circumstances change, or if they cease to qualify for any other reason. • Applicants for the concessionary bus pass must be over 5 years of age, as under 5’s travel free. Itchen Bridge service Where possible the Itchen Bridge concession will be added to the applicants Smartcities card or concessionary bus pass. The Smartcities card or concessionary bus pass must be used at all times on the Itchen Bridge to receive your respective concession. Failure to produce a valid card will result in the appropriate full toll charge being levied and paid for in cash at the time of crossing. If the person to whom the Smartcities card or concessionary bus pass was issued is not in the vehicle then the appropriate toll charge will be made. The Smartcities card or concessionary bus pass must not under any circumstances be deliberately damaged, defaced, altered, copied, passed, loaned, given or sold to a third party. Suspected transactions will be traced through our database and breaches of these terms and conditions could result in: a) Immediate and permanent withdrawal of this concession save where theft has been reported prior to the uses of the Smartcities card or concessionary bus pass. (A police crime reference number will be required). b) The full cash toll being demanded from the driver of the vehicle at the time. c) Possible prosecution d) Administrative charge £15.00 Applicants receiving a concession for the Itchen Bridge crossing must notify Smartcities immediately if their circumstances change, e.g. moving out of the area, or ceasing to receive the higher rate of the mobility component of Disability Living Allowance. The loss of the Smartcities card or concessionary bus pass must be reported within 72 hours to our contact centre on 023 8083 3008. The opening hours are: 8am - 6pm Monday to Fridays. Outside these hours reports can be made to our emergency line: 023 8043 1040. Cards that are lost, stolen or damaged will be replaced after an administration fee is received, unless a police crime reference number is supplied (only one card per year will be reissued free of charge when a crime reference number is provided). The Itchen Bridge provides a toll exemption for people in receipt of the higher rate of the mobility component of Disability Living Allowance. The scheme provides the disabled person with a Smartcities or Concessionary bus pass to enable them free crossing in their class 2 vehicles. Class 2 vehicles are cars and light vans with a height measured at the first axle of no more than 1.40 metres. Concessions are available to residents of Southampton - i.e. Southampton council tax payers only. The concession applies to cars and light vans in class 2 only. • Peak Periods are: Mon-Fri 0700 to 0930 and 1600 to 1830 • Off-peak: any other time as stated above including weekends Any information you provide on this form will be held by Southampton City Council (SCC) in accordance with the Data Protection Act 1998. SCC’s nominated representative for the purposes of the Act is Mark Heath, Solicitor to the Council. If you have any questions relating to the use of your data, please contact Simon Bell on 023 8083 3814. The information you have provided will be used for the purposes of issuing and maintaining your Smartcities card. Your information will be shared with NHS Organ Donor only if you selected that option on your application form and no other third parties unless we are required to do so under legal duty. 17 Less toot toot more cheap cheap Welcome to the world of My Journey Southampton. My Journey is a new initiative we are rolling out across the city with the aim of helping you travel in a more sustainable way. It is all about helping you think differently about the way you travel and finding new ways that are cheap, healthy and as environmentally friendly as possible. Find out more visit www.myjourneysouthampton.com The My Journey Southampton website is a free, one-stop resource for planning journeys around the city and beyond. Whether you are looking to travel by bike, bus, train or by foot, our website should be your first port of call. There is also real time traffic information plus details of car sharing schemes and driving in a fuel efficient way. So no matter how you choose to travel, our website has it all. The following is a summary of what you can find on our website: Cycling Car Whether you are looking for cycle route maps, where to get cycle training or get your bike fixed, this is the place to come. Use the journey planning tool to plan your route – it will show you the quickest or quietest route along with information on the time it takes and even how many calories you’ll burn. There is also a directory of cycle clubs and listings of exiting cycling events around the city. This is THE cycling resource. TWE ET1 Meet the birds To help you get from A to B quickly and easily we have enlisted some help from a few feathered friends. You will see these characters popping up here and there on our My Journey information. Wherever you spot one there will be more information about how you can benefit from using sustainable transport. BasilBelleBettyBernardBertBabsBoo Bus and train travel If you’re looking for bus routes and times – you’ll find it here. In fact you’ll find all the information you need to know about travelling by bus and train in the city and beyond. We understand that the car will always play a big part in our lives, so the website also includes information on car sharing and tips on driving in a more environmentally friendly way – good for your wallet and the environment too. Real time traffic information is provided so you can beat the jams – or choose to travel by bike instead. TW E ET1 Walking Information about guided walks around the city – see Southampton from a different perspective – you’ll be amazed what you might learn. Make sure you bookmark the website as new content is being added all the time. An integrated journey planning tool will be coming soon which will help you join up sustainable travel methods across Southampton and the wider Hampshire region. www.myjourneysouthampton.com Part funded by the Department for Transport 18 www.southampton.gov.uk Southampton City View 19 Useful information Traveline: For public travel information for bus, train, coach, ferry or underground please contact Traveline on 0871 200 22 33 or log on to www.traveline.org.uk Calls cost 10p per minute from a landline plus connection fee. Smartcities: For information about the multi-function Smartcities card, please contact Smartcities on 023 8083 3008 or visit our website www.smartcities.co.uk Libraries: Southampton libraries are your gateway to a world of reading, information and knowledge. Everyone is welcome to use the library and membership is free. To find out more please visit www.southampton.gov.uk/libraries/ or contact us on 023 8083 2459 or email [email protected] Leisure: Active Nation in partnership with Southampton City Council is managing The Quays Swimming & Diving Complex, Bitterne and Chamberlayne leisure centres. For more information about the leisure venues please visit: www.activenation.org.uk Mytime Active in partnership with Southampton City Council operates the Southampton City Golf Course. For more information about the golf course please visit: www.mytimegolf.co.uk or telephone: 023 8076 0546. This written information is available on request in other formats or languages. Please contact 023 8083 3008 for help. www.southampton.gov.uk Version 4 Designed, printed & produced by Southampton City Council 07.12.23631
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