LeisureCardApplicationform
IapplyformembershipoftheLeisureCardschemeandIagreetoabidebythetermsandconditions.
Title: Mr/Miss/Ms/Mrs/Other Forename
Surname Email
AddressPostcode
ContacttelephonenoDateofbirthGendermale/female
Ethnic Origin
Asian orAsianBritishBangladeshi■Indian■Pakistani■Any other Asian background■
BlackorBlackBritishAfrican■Caribbean■Any other Black background ■
ChineseorOtherChinese■Other■
MixedAsianandWhite■BlackAfricanandWhite■BlackCaribbeanandWhite■ Any other Mixed background■
WhiteBritish■Irish■Any other White background■
Do you consider yourself to have a disability that limits your daily activities? Yes ■ No ■
PersonaldatasuppliedwillbeheldoncomputerandprocessedinaccordancewiththerequirementsoftheDataProtectionAct1998.Itwillbe usedforthepurposesofstatisticalanalysis,managementandplanning,andintheprovisionofservicesbytheCouncil.Theinformationwillbe sharedwithUnicardandtheBlackCountryKnowledgeSocietyforthepurposesofoperatingandmanagingtheSmartCardscheme.
ByacceptingmembershipyouareagreeingtobecontactedbyDudleyCouncilregardingtheservicesthatitprovides.Forfurtherinformation regardingtheuseofyourdata,ortocancelyourmembership,pleasecontact01384815587
Signed...... Date
Terms and conditions of membership:
•Cannotbeusedinconjunctionwithanyotheroffer•Membersmustnotifytheirissuingcentreofanychangeinstatus,whichmayaffect theircontinuedeligibility•Cardswillbesentouttotheapplicantshomeaddresswithinsevenworkingdays•Cardmustbeshownpriorto paymenttogaindiscounts•Lostorstolencardsshouldbereportedtotherelevantissuingcentre•Theremaybeachargeforreplacement cards•Thecardisnottransferable•Anymisuseofthemembershipmayresultinthecardbeingrevoked
IwishtoapplyformembershipoftheLeisureCardschemeforthefollowingdependant(s).
A.Nameofdependant(infull).Date ofbirt / Gender male/female......Please enter the dependant’s ethnic origin from the list given abov
B.Nameofdependant(infull).Date ofbirt / Gender male/female......Please enter the dependant’s ethnic origin from the list given abov
C.Nameofdependant(infull).Date ofbirt / Gender male/female......Please enter the dependant’s ethnic origin from the list given abov
D.Nameofdependant(infull).Date ofbirt / Gender male/female......Please enter the dependant’s ethnic origin from the list given abov
E.Nameofdependant(infull).Date ofbirt / Gender male/female......
Please enter the dependant’s ethnic origin from the list given abov
For issuing site use only
MembershippicturereferencenumberExpirydateFeepaid...... Proofofeligibility-Tickthenumberfortherelevantcategoryasdescribedonreverse.
1 ■ 2■ 3 ■4 ■ 567891011121314■15■16■17■18■
Dependants Membership picture reference numbers:
ABC......
DE
IssuedateIssuesiteSigned......
CategoryProof
1.RegisteredJobseekerLetter-JobCentre
2.WorkingTaxCreditAwardnotice/letter
3.IncomeSupportLetter-JobCentre
4.HousingBenefitCouncil letterH94
5.CouncilTaxBenefitCouncil letterH94
6.IncapacityBenefitAwardnotice/letter
7.DisabilityLivingAllowanceAwardnotice/letter
8.Carer’sAllowanceEntitlementletter
9.DudleyCarer’sNetworkLetter fromDudleyCarer’sNetwork
10.BlueBadgeBlue BadgeID
11.Resident-DudleyManagedNeighbourhoodPostcode-recentutilitybill12.AsylumSeeker Proof of residency inDudley
(letter - Housing Services)
plus either Home OfficeARC card or IS96 form
13.FosterfamilyLetter fromDudleySocialServices
14.ChildinresidentialcareLetter fromDudleySocialServices
15.ModernApprenticeLetter from learningprovider
16.FulltimestudentFulltimeStudentUnioncardorcollege enrolmentletter
17.PensionCredit(GuaranteeCredit)Award NoticeLetter
18.AttendanceAllowanceAwardnotice/letter