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Essential Companion Scheme - individual membership application

1) Details of the person with the disability
Label
1. Title:*
2. Initial:*
3. Surname:*
4. Street name and number:*
5. Town:*
6. County:*
7. Postcode:*
8. Phone:
9. Email:
10. Will the person with the disability, listed above, be booking the tickets? *
  
  Yes
  
  No
11. You can provide contact details for the personal representative on the next page.
12. 2) Type of application
13. Application type: *
  
  I am in receipt of the higher rate of the Disability Living Allowance - Care or Mobility Component, the higher rate of Attendance Allowance, the enhanced rate of the Personal Independence Payment - Daily Living or Mobility Component or hold a Certificate of Visual Impairment and would like to apply for a complimentary seat for my Essential Companion.
  
  I am in receipt of the middle rate of the Disability Living Allowance - Care Component, the standard rate of the Personal Independence Payment - Daily Living Component or the lower rate of Attendance Allowance and would like to apply for a 50% ticket price reduction on an adult ticket for my Essential Companion.
14. 3) Evidence of entitlement
  
  Please include a scanned copy of the letter from the Department of Work and Pensions confirming DLA / Attendance Allowance status or Certificate of Visual Impairment. You may cross out any monetary amounts.
15. Upload letter: