Scooter and Wheelchair Travel Pass - Public Transport Victoria

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How to complete this formApplicants• All applicants are required to complete Section 1 andSection 3.• All applicants are required to attach the signed photograph– Section 4.Guardian / Agents• If you are completing and signing this application formon behalf of the applicant you are required to completeSection 1, Section 3 and Section 4.General Practitioner or specialist• The General Practitioner or specialist is required tocomplete Section 2 and sign the reverse of the photograph.Please complete this application form in BLOCK LETTERSusing blue or black pen.Scooter and Wheelchair Travel Pass – Information and application form 10
Section 1: Applicant informationThe Scooter and Wheelchair Travel Pass will only be issued tothe person whose details appear below. One application mustbe completed per applicant.Please tick all relevant boxes where applicable.1.1 Applicant’s detailsTitle: Mr Mrs Miss MsSurname or family name:First or given name:Date of birth: / / Male FemaleResidential address:Suburb:State:Postcode:Postal address:Suburb:State:Postcode:Phone – home:Phone – mobile:Email (if available):Scooter and Wheelchair Travel Pass – Information and application form 11
Page 1 and 2: Scooter and WheelchairTravel PassIn
Page 3: Why has the Scooter and Wheelchair
Page 6 and 7: How do I obtain a replacement card?
Page 8 and 9: Step 2Applicant / Guardian / Agent
Page 12 and 13: 1.2 Are you a permanent resident of
Page 14 and 15: Section 2: General Practitioner ors
Page 16 and 17: 2.6 General Practitioner or special
Page 18 and 19: • I declare that I am a resident
Page 20 and 21: Section 4: Photograph35mmJOHN SMITH
Page 22 and 23: ManoeuvrabilityThe mobility aid sho
Page 24 and 25: 5. PTV may change these terms of us
Page 26 and 27: Section 8: Contacts formore informa

Scooter and Wheelchair Travel Pass - Public Transport Victoria

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