This form is for new applicants only. Do not use this form to get a replacement card. Before completing this form, please read the terms and conditions, available at If you require help completing this form please contact Customer Service on 01382 433267. Please use BLACK or BLUE ink and write in block capitals within the white boxes.

PART 1: Personal Details and Photograph

Title______

First Name*______

Middle Name(s)______

Surname*______

Date of Birth*___/___/______

Gender*MaleFemale

Address*______

______

City*______

Postcode*______

Telephone______

Mobile Phone______

Email address______

PART 2: Your Data

By signing this form you give Dundee City Council permission to hold your data to produce, administer, and replace your card if necessary. If you live outside Dundee, Dundee City Council will pass your information to your Local Council for processing your card.

As explained in the terms and conditions, the Council will share your data within the council, with other Scottish Councils or with public bodies for the purpose of maintaining the integrity of your data and the associated entitlements or for preventing, detecting or investigating fraud. If you do not wish to share data please opt out here

Note – Sharing information with these organisations will NOT lead to you receiving junk mail

PART 3: Young Scot, EURO Under 26 and PASS holgram (See PAGE 2)

If you are aged between 12 and 26 your card will have the Young Scot and European Under 26 (EURO<26) logos and a proof of AgePASS hologram. If you do not want this on your card, please opt out below.

I DO NOT want Young Scot, EURO<26 or PASS Hologram on my card.

CAUTION: Making a false declaration is a criminal offence for which you may be fined or imprisoned.

PART 4: Applicant’s Declaration

I accept the Terms and Conditions upon which my card is issued. I confirm that, as far as I know, the details I have provided are complete and accurate and I understand that you may take action against me if I have provide false information or if I misuse the services provided. I understand that I must promptly inform my local council of any changes that may affect my entitlement to services.

Applicant’s SignatureDate /  / 

STAFF USE ONLY
Photo Driving Licence* NEC / PASSCard*
Current Passport* Photo Referee
* No Photo Referee required for these proofs / Official Stamp:

RECEIVEDInitialsDate  /  / 
PROCESSED Initials Date  /  / 

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