Disabled Persons Concessionary Bus Pass

Application Form
This application form is only for blind or disabled persons. The applicant must be a permanent resident
in the Nottinghamshire County Council area, of which proof will be required. All applicants must
have a disability that is considered long term (in excess of 12 months).

There is no charge for this pass; however there is a fee payable if you require a replacement. For
a replacement please fill in the Replacement Concessionary Bus Pass Application Form.

If you have any difficulties or enquiries regarding the completion of this form,
please telephone 0300 500 80 80.

Please note that in certain circumstances we are required to complete additional checks concerning the
information you have submitted on the form.

Is this a new or renewal application.

IN ORDER TO OBTAIN YOUR PASS

YOU WILL NEED TO ENCLOSE A COPY
A ABOUT YOU OF
Title: Mr / Mrs / Miss / Ms / Other: ....................................................... (Please DO NOT send original
documents)
First Names: ...........................................................................................................
1 x Proof of Age/Identity
(Birth Certificate, Passport,
Surname: ................................................................................................................... Driving Licence or Medical Card)

Previous / Maiden Name: ........................................................................... PLUS

1 x Proof of Disability
Address: .................................................................................................................... (Please see overleaf)

............................................................................................................................................ PLUS

1 x Proof of Residency
............................................................................................................................................
(Utility Bill or Bank Statement dated within
the last 3 months or current year Council
Postcode: ................................................................................................................. Tax Bill)

PLUS
Date of Birth: .................................. / ................................. / ...............................
1 x Passport Sized Photo
Telephone Number: ........................................................................................ (With your name written on the reverse)

Please post your completed application form to the

E-mail address: ...................................................................................................
address on the back page.

Revised July 2018

B YOUR DISABILITY D PROOF OF DISABILITY
(MUST BE COMPLETED) (Section B must be completed)
Nature of Disability 1. Do you receive the higher rate Yes No
(Please tick all that apply) mobility Component of Disability
Yes No Living Allowance?
1. I am registered/eligible for registration
as blind or partially sighted. 2. Do you receive War Pensioners Yes No
Yes No Mobility Supplement or Armed Forces
2. I am registered/eligible for registration Compensation Scheme Tariff Level 1-8.
as profoundly or severely deaf.
Yes No 3. Are you registered Blind or Partially Yes No
3. I am registered/eligible for registration Sighted?
as a person without speech.
4. Do you receive Personal
4. I have a disability / have suffered an Yes No Independence Payment (PIP) with an
Yes No
injury, which has a substantial and award of at least 8 points for ‘Moving
long-term adverse effect on my ability Around’ or ‘Communicating Verbally’
to walk. activities?
5. I am without the use of both arms Yes No IF YOU HAVE ANSWERED ‘YES’ TO
(through loss of limbs) or long-term use ANY OF THE ABOVE, PLEASE SEND
of both arms. DOCUMENTED PROOF AND GO
DIRECTLY TO SECTION F
6. I have a learning disability, that is,
a state of arrested or incomplete Yes No IF YOU HAVE ANSWERED ‘NO’ TO
development of mind which includes ALL OF THE ABOVE PLEASE GO TO
significant impairment of intelligence SECTION E
and social functioning.
7. I have been refused a driving licence
(or had it withdrawn) on medical
Yes No
COMPANIONS
grounds under part III, Section 92 of
the Road Traffic Act 1988. You can apply for a pass with companion’s
IF YOU ANSWERED ‘YES’ TO  entitlement if you are unable to board
NUMBER 7 GO TO SECTION C public transport without assistance and
IF YOU ANSWERED ‘NO’
meet at least one of the qualifying criteria
TO NUMBER 7 GO TO SECTION D below.

1.You are blind

C ONLY FOR PERSONS
APPLYING ON THE 2. You have a severe walking disability
GROUNDS OF REFUSAL /
WITHDRAWAL OF A DRIVING 3. You have a severe learning disability
LICENCE
People who would be refused a driving If you wish to request a pass with
licence (or have had it withdrawn) due to companion’s entitlement, please tick here
alcohol or drugs misuse are not eligible AND GO DIRECTLY TO SECTION E
for a disabled pass.
Yes No TO APPLY FOR A COMPANIONS PASS
Have you had a Driving Licence refused
or revoked on medical grounds? A MEDICAL PROFESSIONAL MUST
SIGN AND STAMP THE COMPANIONS
IF YOU HAVE ANSWERED ‘YES’ TO THE SECTION OF SECTION E.
ABOVE, PLEASE SEND DOCUMENTED
PROOF AND GO DIRECTLY TO SECTION
F OR GO TO SECTION E IF NO PROOF
AVAILABLE.
IF YOU HAVE ANSWERED ‘NO’ TO ALL OF
THE ABOVE PLEASE GO TO SECTION E

Continued overleaf
E MEDICAL PROFESSIONALS CERTIFICATE
To be filled in by a medical professional (e.g. General Practitioner, Hospital Consultant or Psychiatrist, Community
Psychiatric Nurse).
Name of health professional……………………………………......................Job title……………………………..............

I certify that (applicants name)……………………………………….........................................

Has an injury / disability as detailed below:
Your official
......................................................................................................................................................... stamp

.........................................................................................................................................................

Please Complete all applicable

1.. is registered / eligible for registration as blind or partially sighted

Signed.......................................................................................................................................................Date..........................

2. i.s registered / eligible for registration as profoundly or severely deaf

Signed.......................................................................................................................................................Date..........................

3.. is registered / eligible for registration as a person without speech

Signed.......................................................................................................................................................Date..........................

4. h
. as a disability which will last at least 12 months and means that he/she cannot walk or
is virtually unable to walk, due to..................................................................................................................................

Signed.......................................................................................................................................................Date..........................

5. is without use of both arms, due to..............................................................................................................................

Signed.......................................................................................................................................................Date..........................

6. has the following learning disability.............................................................................................................................

Signed.......................................................................................................................................................Date..........................

7.. Would be likely to be refused a driving licence on medical grounds, due to..........................................................

..........................................................................................................................................................................................

Signed.......................................................................................................................................................Date..........................

People who would be refused a driving licence (or have had it withdrawn) due to alcohol or drugs
misuse are not eligible for a disabled pass.

Anticipated duration of disability: Companion

The applicant’s illness is Permanent: If you have signed 1, 4 or 6 above, can the
applicant only use public transport with the
Temporary (greater than 12 months assistance of a companion?
but not permanent): Please see criteria on opposite page.

Yes No
If temporary please specify
expected term of illness months
Signed:..............................Dated:......../........../...........
F YOUR DECLARATION
I apply for a concessionary Bus Pass and declare that the information given herein is true and complete. I will
notify the Council of any change in my circumstances that may affect my application and understand that the
Council may be writing to the DWP or to my medical professional to ascertain my eligibility for this scheme.

I certify that the above details are correct. I further acknowledge that I am aware that the bus pass is the
property of Nottinghamshire County Council and I undertake to return it to the Council if it is no longer required
by me or its return is formally requested by an authorised officer of the Council.

The personal information collected on this form will be processed on computer to provide and manage the
information or service that you have requested. For further details regarding your privacy, please see our
Privacy Statement: http://www.nottinghamshire.gov.uk/privacy/

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 to administer concessionary travel and 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.

I have supplied copies of the required documents. (PLEASE DO NOT SENT ORIGINALS).

Please Sign Here..................................................................................................Date........./........../.........

Print Name.....................................................................................................................................................

Please ensure you have completed all the necessary sections before returning to.

Transport and Travel Services

PO Box 1889
Nottingham
NG2 9RU

PLEASE NOTE THAT WE DO NOT OFFER A WHILE YOU WAIT SERVICE.

FOR OFFICE USE ONLY

Date Received ................................................................................... Pass Number .......................................................................

Date Pass Issued.................................................................................. Companion Pass Yes / No

Initials .......................................................... ID ......................................................... Residency .........................................................

D&P/08.19/6798