Dial-A-Lift Individual Application Form

Dial-A-Lift Individual Application Form
Unfortunately, we are unable to accept new memberships due to budget cuts and service pressures.

The situation remains under review.

We apologise for any inconvenience.

DART Partnership

10 Charlestown Avenue

Portadown

BT63 5ZF

(028) 3831 7810

www.dartpartnership.co.uk
INDIVIDUAL APPLICATION FORM
This form can be used to register indivduals or group members who wish to register as part of a group for purposes of traveling together. If you are a concessionary (bus pass) holder, you will be able to travel on this service for FREE or HALF-FARE. If you are not sure if you live within the DART operational area (which is the old legacy council areas of Craigavon and Banbridge) please telephone the office on 028 38 317810 for help completing this form.
PERSONAL DETAILS
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Date of Birth*

DayMonthYear
Date
Phone Number*
Please enter a valid phone number.Format: 00000000000.
Mobile Number
Please enter a valid phone number.Format: 00000000000.
Email
example@example.com

Smart Pass Information
YesNo
65+60+Half FareWar DisabledBlind
Pass Number:
Pass Expiry Date:

DayMonthYear
Date
The SmartPass information you provide will be processed to enable the Department for Infrastructure (the Data Controller) to manage and administer Assisted Rural Travel Scheme. Your personal data may also be shared, if necessary, with enforcement agencies for the purpose of the prevention and detection of crime. More detail on how your information is included on the Northern Ireland Concessionary Fares Privacy Notice which is available to view at:

www.infrastructure-ni.gov.uk/publications/gdpr-privacy-notices-dfi-business-areas

EMERGENCY CONTACT DETAILS

Please provide details of a relative, friend, neighbour, carer or social worker who could be contacted on your behalf in the event of an emergency
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: 00000000000.
Mobile Number
Please enter a valid phone number.Format: 00000000000.
Relationship to applicant:
Name: *
Relationship to you:   *
Telephone Number:   *
Mobile Number:

DATA PROTECTION

By submitting your application, you are providing consent for us to process your personal information as detailed below.We will use the personal information we collect about you to: • Consider your application/membership for community transport services. • Provide you with community transport services if your application is successful. • Comply with legal or regulatory requirements. It is in our legitimate interests to decide whether we can provide community transport services to you and, if your application is successful, to provide those services to you, as it would be beneficial for our business to do so. We also need to process your personal information to decide whether to enter into a contract for the provision of community transport services with you. Having received your application form, we will process that information to decide whether you qualify to receive our community transport services. If we do agree to provide you with community transport services, then we will use the personal information to provide you with those services. Unless you request us not to do so, we will share the information in the section headed “Equality Information” with the Government department that provides our funding. This information will be shared for equal opportunity and/or diversity monitoring and reporting and will only include the information set out in that section.
DECLARATION

This is a Down Armagh Rural Transport Partnership (DART) Ltd individual membership form for Dial-A-Lift services.

I confirm that the information I have given is correct and that I am responsible for ensuring that DART is kept informed of any relevant changes in my personal health or circumstances.

I understand that if i do not sign this form that my application will not be processed.

I understand that by signing this form, I agree to abide by the terms and conditions of the membership set out by DART and that all the information provided within this form is true and accurate.

I understand that my membership can be refused or revoked if this information is incorrect, if I fail to inform DART of any relevant changes to my personal health/circumstances or if I fail to comply with the terms and conditions of the membership
Signature*
Date

DayMonthYear
Date
Under 16's applications must be countersigned by a parent/guardian.
Counter Signature
If you are signing on behalf of the applicant, please print your name and relationship to them eg: friend/relative

Name:
Relationship:
A copy of our passenger charter will be sent out to you once your membership has been processed.
Could you please give us some basic/helpful directions to your house which can be passed on to our driving staff:
Should be Empty:

Dial-A-Lift Individual Application Form

INDIVIDUAL APPLICATION FORM

PERSONAL DETAILS

Eligible Membership Criteria

Smart Pass Information

EMERGENCY CONTACT DETAILS

TELL US ABOUT YOURSELF

EQUALITY INFORMATION

DATA PROTECTION