Scooter and Wheelchair Travel Pass - Public Transport Victoria

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Section 2: General Practitioner orspecialist’s declarationPlease ensure that all sections are completed to prevent theapplication being returned to you and delay in processingthe application. Your complete answers to questions are criticalin the assessment of the applicant’s eligibility.Please tick all relevant boxes where applicable.Assessment2.1 Does the applicant permanently (being for the term oftheir life and not expected to improve) depend on theuse of a wheelchair for mobility outside their home,due to their disability?YesNoOR2.2 Does the applicant permanently (being for the term oftheir life and not expected to improve) depend on theuse of a scooter for mobility outside their home, dueto their disability?YesNoScooter and Wheelchair Travel Pass – Information and application form 14
2.3 Please provide comment below if there is any furtherrelevant information you would like to add.2.4 Please indicate in what capacity you have madethis assessment.General PractitionerSpecialistPlease note: Remember to sign the back of theapplicant’s passport photograph, certifying it is a truelikeness of the applicants (state their full name).2.5 My signature which appears on the next pageconfirms all of the following:• I have read all the information provided by the applicanton this form and verify that it is correct to the bestof my knowledge.YesNo• I am not the applicant or an immediate family memberof the applicant.YesNo• I agree to offer all reasonable information to assist theScooter and Wheelchair Travel Pass Panel to determinethe applicant’s eligibility.YesNo• I have signed the reverse of the applicant’s photographand confirm it is a true likeness of the applicant.YesNoScooter and Wheelchair Travel Pass – Information and application form 15
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 10 and 11: How to complete this formApplicants
Page 12 and 13: 1.2 Are you a permanent resident of
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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