Apply for your

Disabled Persons Concessionary Travel Pass

An Easy Read Application Form

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About the travel passYou can get the Travel Pass from Centro if:

l You are over five years old

l AND you have a disability

l AND you have been disabled for a long time, or you will be disabled for the next 12 months or more.

With the Travel Pass you can travel free:

l on the bus anywhere in England

l on the train or Metro anywhere in the Network West Midlands Zone.

You can use the Travel Pass:

l Mondays to Fridays, from 9.30 in the morning until the end of the day

l Saturdays, Sundays and Bank Holidays, any time of the day.

Can I apply for a Travel Pass?The law says you can apply for a travel pass if your disability comes under one of these seven categories:

A - You are blind or you can only see a little

B - You cannot hear or you can only hear a little

C - You cannot talk83

D - You have a disability or injury that makes it

difficult to walk.

E - You cannot use both arms

F - You have a learning disability

G - A medical condition stops you from holding a driving licence because you:

l Have fits you cannot control (this is called epilepsy)

l Have severe mental health issues

l Have serious memory problems (this is called dementia)

l May suddenly faint or black out

l Cannot read a car number plate in good light when the car is just over 20 metres away

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How to applyCentro can provide free travel passes to people living in the West Midlands area, including these towns and cities:

l Birmingham

l Coventry

l Dudley

l Sandwell

l Solihull

l Walsall

l Wolverhampton

What to do nextComplete Parts 1 to 7 on Pages 7 to 21

You can fill in the form yourself or a family member or support worker can fill it in with you.

It is important you complete all of the boxes in this form and provide the correct documents.

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How to contact usFor more details about getting a Concessionary Travel Pass please visit www.networkwestmidlands.com

If you would like help to complete this form, or you would like the form in another format:

Call us on Tel: 0845 303 6760

Email: customerrelations@centro.org.uk

Need to speak to someone in a different language?

We use Language Line’s telephone service for people who need to speak to someone in another language.

To call Language Line phone: 0845 303 6760

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Completing this formPlease tick and fill in all the boxes in Parts 1 to 7.

The form has been set up so that you, or someone else, can fill it in on your computer.

Then you will need to print out the form, sign it and post it to us.

Your Photo Stick your passport photo in this box.

Write your name and postcode on the back of the photo.

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t

Part 1: About youYour title: Mr n Mrs n Miss n Ms n

Othern

First name:

Middle name:

Last name:

Address:

Postcode:

Telephone Nos:

Daytime

Evening

Mobile No

Email address

Are you: Male? n Female? nWhat is your date of birth?

dd n mm n yyyy n

What is your National Insurance Number?

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Which local council do you pay council tax to?

n Birmingham

n Coventry

n Dudley

n Sandwell

n Solihull

n Walsall

n Wolverhampton

Do you hold a full driving licence?

n Yes, a full licence

n Yes, a provisional licence

n No

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Part 2: Your doctorYour doctor’s name

Address

Postcode

Telephone No

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Part 3: Disability and healthYou must provide documents about your disability.

We have listed the documents you need to send us for each category.

Please tick the box by the category that applies to your disability.

n A – I have visual impairment

If you are blind or can only see a little we need to see ONE of these documents.

Please tick the box next to the document you are sending us.

n Proof you are registered blind

n Certificate of Vision Impairment (CVI)

n Letter from an eye specialist that says you are blind or have poor eyesight

n B – I have hearing impairment

If you cannot hear or can only hear a little we need to see ONE of these documents.

Please tick the box next to the document you are sending us.

n Proof you are registered deaf

n Report from a specialist that says you cannot hear very well (75 to 90 dBHL in both ears).

n C - I have a speech problem

If you cannot talk we need to see a letter from a medical professional that says you cannot make basic requests by speaking.

Please tick the box if you are sending us a letter.

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A

n D – I have a disability or injury that makes it difficult for me to walk

If you have difficulty walking please answer questions 1 to 4.

1) Do you get Disability Living Allowance (DLA)?

Yes n No n

2) Do you get Personal Independence Payments (PIP)?

Yes n No n

If you have answered ‘Yes’ to either question 1 or 2 we need to see:

n a letter from the Department of Works and Pensions (DWP), that is less than 12 months old, stating you have a DLA or PIP, and for how long.

Please tick the box if you are sending us a letter.

If you need help to get a letter you can call the DWP on: 08457 123 456

3) Do you get the War Pensions Mobility Supplement?

Yes n No n

4) How far can you walk before you:

l Have to stop

l Are in pain, or

l Need help from someone else?

I can walk for n Metres or Yards

You may need to attend an assessment so that we can check this information is correct.

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A

n E – I CANNOT use both arms

If you are unable to use either of your arms we need to see:

n a letter from a medical professional stating you cannot use your arm or arms for daily tasks.

Please tick the box if you are sending us a letter.

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n F – I have a learning disability

If you have a learning disability you may find it difficult to understand complex things or to do daily tasks such as:

l Household jobs

l Meeting new friends

l Managing your money

If you have a learning disability we need to see one or more of these documents.

Please tick the box next to the document or documents you are sending.

n a letter from social services or an organisation providing you with support stating you have a learning disability

n a letter from a manager of a residential home or sheltered housing stating you have a learning disability

n a letter from a medical professional who cares for you stating you have a learning disability

n a statement of Special Educational Needs

n a letter from the head of the special school you go to stating you have a learning disability

n a letter from the disability co-ordinator from the school you go to.

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8n G- I cannot drive a car because of my

disability

Have you ever been told you cannot have a driving license because of your disability or health needs?

Yes n No n

Has your driving license been taken away due to your health needs?

Yes n No n

Can you tell us more about this?

If you cannot drive a car because of your disability we need to see one or more of these documents.

Please tick the box next to the document or documents you are sending.

n a letter from DVLA stating you cannot get a driving license for at least 12 months

n a letter from a medical professional stating you would be refused a driving license if you applied for one

n proof of any medication you take.15

Part 4: ChecklistPlease check you have included all the documents we need.

We recommend that you send this application and other documents by recorded delivery.

Please tick each box to check that you are sending us the correct information.

n A passport photo with your name and postcode written on the back

n Proof of your address such as a bank statement or a letter from the DWP, dated in the last six months

n Documents needed for the Category of your disability (listed in Part 3 of this application form)

n Any other documents to help your application.

n Please send copies, or the original copy of a proof of medication.

If you do not send us the correct information we will return your application.

Please note: If you need to get a document from a GP they may charge you.

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Part 5: DeclarationPlease tick all the statements below to show they are true

n Statement 1 My disability has lasted, or is likely to last for 12 more months.

n Statement 2 I agree that Centro may need to check that the information in my form is correct and may contact

l A medical professional

l Social services

l A support organisation

l Department of Work and Pensions

l A manager of a care home or sheltered housing

l DVLA (Driving and Vehicle Licensing Agency)

n Statement 3 If I apply under Category D (on Page 12) I understand I may need to have an assessment. If I do not go to the assessment I may be charged.

n Statement 4 If I get a travel pass:

l I will tell Centro when there are relevant changes in my personal life.

l I will tell Centro if I move home.

l I will return my pass if I move outside the West Midlands area

l The pass belongs to Centro and must be returned if it is misused.

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n Statement 5

If I lose my pass I will pay for a new one.

To find out more about the fee call 0845 303 6760 or visit www.networkwestmidlands.com

I agree that all information kept about me is in line with the law (Data Protection Act 1998)

Your signature Signed

Date

If another person has helped you fill in this form what is their name?

What is their relationship to you?

What is their phone number?

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Part 6: What the law says about personal information

The padlock symbol tells you that we carefully manage personal information about you.

We may use the information to tell you about new products and services.

And we may share your information with the police or other agencies to prevent crime.

For more information about the Data Protection Act 1998 please visit www.networkwestmidlands.com

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Part 7: More information about youWe want to be sure that we offer a fair and equal service to everyone. To help us do this, please tick the box that describes your ethnic origin. We will keep this information private and safe.

White

n British n Irish

Any other white background (please write/type in the box below)

Mixed

n White and black Caribbean

n White and black African

n White and Asian

Any other mixed background (please write/type in the box below)

Asian or Asian British

n Indian, n Pakistani or n Bangladeshi

Any other Asian background (please write/type in the box below)

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Black or black British

n Caribbean African

Any other mixed background (please write/type in the box below)

Chinese or other ethnic group

n Chinese

Any other ethnic group (please write/type in the box below)

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Please post the completed form and all the documents listed on Page 13 to:

Centro, PO Box 9421, Birmingham, B19 3TR

It can take up to eight weeks to get your travel pass.

If the form has not been completed or you do not provide the right documents it could take longer.

If we need more information we will write to you.

Thank you for completing this form.

We will be in touch soon.

This Easy Read booklet was written and produced by

www.easy-read-documents.com