Registration form for Social Welfare Services FT 1 …

1 7. Your date of birth: 5. Your birth surname: Registration form forFree travel Scheme Please answer all questions. Please use blackball point pen. Please use BLOCK LETTERS and place an X in the relevant boxes. If you already hold a Public Services Card free travel and it is lost, stolen ordamaged, please phone 1890 83 7000 to request a replacement - DO NOT completethis form . If you want to replace a lost, stolen or damaged paperFree travel Pass, please call071 915 7100 or LoCall 1890 500 Your mother s birthsurname: I declare that the information given by me on this form is truthful and complete and that Ipermanently live in the Republic of Ireland.

2 I acknowledge that another individual is not entitled to usemy card at anytime. I undertake to immediately advise the Department of any change in mycircumstances which may affect my continued parent or guardian must sign declaration in respect of applicants under 16 DMMY Y Y YPlease attach your birthcertificate if born outside theRepublic of own detailsPart 1 Data Classification RSocial Welfare ServicesFT 11. Your PPS No.: 3. Surname:4. First name(s):2. Title: (insert an X orspecify) (notblock letters)Date:D DMMY Y Y Y20 Warning: If you make a false statement or withhold information, you may beprosecuted leading to a fine, a prison term or Your telephone number:L A N D L I N EM O B I L E8.

3 Your address: CountyContact you are a Widow, Widower or a Surviving Civil Partner aged 60 - 65, did your late spouse or civil partner have a free travel Pass from this Department?Please attach your marriage certificate or civil partnership orcivil union Registration certificate if married or registered outsidethe Republic of :First name(s):Date of birth: D DMMY Y Y YPPS No: Your own detailsPart 1 you are married, in a civil partnership or cohabiting, from what date?D DMMY Y Y you?SingleMarriedSeparatedDivorcedWidowe dCohabitingIn a Civil PartnershipA surviving Civil PartnerA former Civil Partner(you were in a Civil Partnershipthat has since been dissolved) YesNoIf Yes , please state address:Type of payment:Source of payment:If Yes to either of the above, please attach payment statement and state: Please answer the following questions if you are under 66.

4 If you are over 66, please proceed to Part you getting an occupational pension? you getting a Social security payment from another country?If you are getting a payment from any other agency please give your insurance or claim number:Your claim detailsPart 2 YesNoYesNoWere you living with your late spouse or civil partner at the time of their death? YesNoIf your spouse, civil partner or cohabitant wish to apply to travel for free with you when youtravel, please fill in the following details: free travel for your spouse, civil partneror cohabitantPart date of birth: surname: s birthsurname: D DMMY Y Y YPlease attach their birth certificate if born outside the Republic of PPS No.

5 : first name(s) : (insert an X orspecify) travel companion PassYou may be eligible to get a free travel Companion Pass if you are medically assessed as unfit totravel alone. This type of pass allows any one person, aged 16 or over, to travel for free withyou. For more information, log on to you wish to apply for a free travel Companion Pass?If you are applying for a free travel Companion Pass, we will send you another form for 4 YesNoFree travel companion card in respect of ablind person or a visually impaired you are registered as a blind person,you mustprovide documentary evidence or have a person from the National Council for the Blind or the National League of the Blind complete the following.

6 The person named in Part 1is registered as a blind person with our or League Official StampIf you are under 18 years and not registered as ablind person with the National Council for theBlind or the National League of the Blind, pleaseattach recent medical evidence of a visualimpairment from your eye 5 Signature(notblock letters)Date:D DMMY Y Y Y20 Send this completed application form and relevant documents to:180K 03-16 Edition: March 2016 free travel SectionSocial Welfare Services College RoadSligoTelephone: 071 915 7100 LoCall: 1890 500 000If you are calling from outside the Republic of Ireland please call: + 353 71 915 7100 Data Protection StatementThe Department of Social Protection will treat all information and personal data you give us asconfidential.

7 However, it should be noted that information may be exchanged with otherGovernment Departments / Agencies in accordance with the and terms used in this form are intended as a guide only and are not a legal remember to sign the Declaration in Part you have any difficulty in filling in this form , please contact your local Citizens InformationCentre, your local Intreo Centre or your local Social Welfare free travel card is a very valuable document and is for your own personal use only andis not transferable to any other person. Under no circumstances is another individualentitled to use your free travel card at any time. The card remains the property of theDepartment of Social Department aims to provide a high quality service in a safe and secure environment andthis extends to our service providers.

8 It is our duty to ensure, insofar as is reasonablypracticable, the health, safety and Welfare of all our customers, employees and members ofthe public. Conditions of use for the free travel Card are subject to the bye-laws, regulations andconditions of, or applicable to, the transport companies. However, if it is reported that a person is consistently abusing their free travel entitlementby either wrongfully presenting a card for travel or engaging in anti Social behaviour whileusing the card, the Department will review that person s free travel entitlement. Note:The r ates ch arged f or t he u se o f 1890 (LoCall) n umbers m ay v ary a mong d ifferent s ervice p :If you are entitled to free travel and not registered for the Public Services Card, youwill have to register before your Public Services Card free travel is issued to free travel passes are no longer being issued.