Total Mobility Assessment

Total Mobility Assessment

This form does not guarantee of Acceptance for a Total Mobility card. Please ensure all questions are answered.
Date of Application

MonthDayYear
Date
Name of TM Client

First NameLast Name
Address

Street Address

Street Address Line 2

City

Post Code
Email
example@example.com
Phone Number

Area CodePhone Number
Date of birth

DayMonthYear
Date
Has the applicant previously used the Total Mobility scheme in any region?
Private and health information is being collected to determine their eligibility for the Total Mobility scheme
The information will be stored for the duration of the client's membership of the Total Mobility scheme
The client has access to their own information and may ask for it to be corrected
What is the Primary cause of the applicant's impairment?Please select the one answer that is most applicable
Please select all that apply regarding your ability to use public transport. The more detail you can share, the better we can understand your needs and assess your eligibility for the Total Mobility scheme
Eligibility Length
Get to or from the nearest public transport stop or station without assistance
Stand and wait without assistance for public transport (where there is no seat).
Get on or off public transport without assistance.
Handle money or tickets without assistance
Travel securely on public transport without assistance...
Travel on public transport without getting confused or anxious
Does the applicant use any of the following mobility aids? Please answer all
Manual Wheelchair
Electric Wheelchair
Scooter
Walking Frame
Walking Stick
Guide Dog
Travel Buddy
Crutches
Please supply further information to support this application.
Does the applicant require the use of a wheelchair accessible vehicle to travel?
Is the applicant in full time dependant care funded by the Government Health System?
Transport Related Financial Assistance Details If Applicable e.g. ACC, Work and Income
Please state where you will use your TM Card. e.g Hospital visit, shopping, family visits.etc and How often you will use it. (e.g doctors 2 x a week, shopping 4 x a month, chemist etc)
Please upload a recent clear head and shoulders photo of yourself. This can be taken with your phone. Please do not upload your drivers or passport photo as this will not be accepted.

Cancelof

Pay via credit/debit card. Your form will be processed within 48 hours.

Assessment Service Fee

This fee includes credit card fee

$72.50 NZD Quantity

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Thank you for submitting your assessment form. We will be in touch soon.
Should be Empty:

Total Mobility Assessment

Pay via credit/debit card. Your form will be processed within 48 hours.*

Pay via credit/debit card. Your form will be processed within 48 hours.