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Taxicard Application Form
1. Information about the applicant
Title: (Mr, Mrs, Miss, Ms, other):
First Name:
Surname:
Gender: Male Female Date of Birth (DD/MM/YYYY):
Address:
Town: Postcode:
Contact Number: Email:
2. Blue Badge disabled persons parking scheme
Do you currently hold a Blue Badge? Yes No
If “Yes” please complete the following:
What is the number on the badge?
What is the expiry date of the badge? (DD/MM/YYYY):
Are you a driver?
Yes
No
Or Passenger? Yes No
Or both?
Yes No
3. Taxicard
Do you currently hold a Taxicard? Yes
No
If “Yes” what is the is the number on the badge:
3. Proof of Identity
You must provide one example of proof of Identity.
(These should be photocopies. Please do not send originals as these cannot be returned to you).
Copy of Valid Driving Licence Copy of current Passport
Copy Birth Certificate/ Adoption Certificate Copy of Civil Partnership/Dissolution Certificate
4. Proof of Residence
You must provide one example of proof of Residence.
(These should be photocopies. Please do not send originals as these cannot be returned to you).
Copy of current Council Tax Bill/Letter (dated in the last 12 months)
Copy of utility bill/letter e.g. gas, electricity, phone or bank/Post Office (dated in the last 12 months)
5. Photograph
Please enclose one colour Passport Size Photograph taken within the last 12 months (youcanalsosendasmartphone
image)
.
6a. Your Health
Please describe any medical conditions/disabilities which affect your walking (please state the medical terms for the
condition/s):
Please return form to: Infrastructure, Room 1.33 John Muir House, Brewery Park, Haddington, East Lothian EH41 3HA
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6b. Your Mobility
Are you able to use public transport? Yes
No
If “Yes” please complete the following:
All the time Sometimes If sometimes, how often?
Do you require assistance? Yes
No
If “Yes” please complete the following:
All the time Sometimes If sometimes, how often?
Do you use any of the following walking aids:
Crutch/s Walking stick/s Walking Frame Rollator
Wheelchair Other (Please describe):
How far would you estimate you are able to walk, using any walking aids, before you feel severe discomfort?
(Please state the distance in metres or yards using whichever me
asure is best for you)
Metres: Yards:
When answering this question please note that:
The average adult step i
s just less than one metre, which is 1.1 yards or 3 feet and 4 inches.
If you walk alongside someone and they take 100 steps you would have walked roughly 90 metres, or 100 yards.
The average double-decker bus is about 11 metres, or 12 yards, long.
A tennis court is about 24 metres, or 26 yards, long.
A full size football pitch is about 100 metres, or 110 yards, long.
7. Declaration
By ticking this, I confirm that the information provided is accurate.
By ticking this, I understand that I may be required to undertake an asse
ssment with a healthcare professional who
aaais independent in order to determine my eligibility for a taxi card.
By ticking this, I consent to East Lothian Council che
cking a
ny information already held by other East Lothian
Council departments on the basis that:
It can help determine my eligibility for a Taxi Card;
It may speed up the processing of my application;
It may enable a decision to be made without the need for a mobility assessment.
Name: Date:
7. Summary Privacy Statement
East Lothian Council is committed to safeguarding your personal information. Our privacy statement reflects current
principles and standards on handling personal information.
1. Purposes for collecting personal information
We use personal information for the following purposes only:
to communic
ate with customers, other services within East Lothian Council and outside contractors i.e. Taxi
operators
to fulfill your requests for services or information
for administration purposes
to comply with any applicable law, regulation, legal process or government request
2. Limiting the Collection of Personal Information
ELC limits its collection of personal information to only that information which is necessary for the identified
purposes
we will keep your personal data in line with our data retention policy, called a Retention Schedule
MoreinformationcanbefoundinourmainPrivacyStatementatwww.eastlothian.gov.uk/taxicards
Please return form to: Infrastructure, Room 1.33 John Muir House, Brewery Park, Haddington, East Lothian EH41 3HA
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