Scooter and Wheelchair Travel Pass - Public Transport Victoria

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2.6 General Practitioner or specialist detailsName:Employer / business name:Business address:Suburb:State:Postcode:Business phone number:Signature:Date: / /Australian Health Practitioner Regulation Agency(AHPRA):AHPRA registration number:Professional stamp:Scooter and Wheelchair Travel Pass – Information and application form 16
Section 3: Applicant / Guardian /Agent declarationPlease tick all relevant boxes where applicable.3.1 I confirm that the signature on the next page verifiesthe following:• I have a permanent and severe disability (being for theterm of my life and that is not expected to improve)which means that I am required to use a scooter orwheelchair for mobility outside my home.YesNo• I authorise public transport authorities to verify theinformation contained in this form, and to obtain anddisclose any information relating to this applicationfor the purpose of assessing my eligibility for aScooter and Wheelchair Travel Pass. This may includeobtaining information held by government departmentsand agencies, and disclosing information contained inthis form or obtained in connection with this applicationfor the purpose of assessing eligibility.YesNo• I agree that the General Practitioner or specialist whocompleted Section 2 of this application may discloseinformation about me to Public Transport Victoriato assist with the assessment of my application.YesNo• I declare that the information in this application is correct.YesNoScooter and Wheelchair Travel Pass – Information and application form 17
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 14 and 15: Section 2: General Practitioner ors
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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