TRANSPORT DEPARTMENT DIAL-A-RIDE PUBLIC TRANSPORT

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TRANSPORT DEPARTMENT
DIAL-A-RIDE PUBLIC TRANSPORT
APPLICATION FOR SPECIAL NEEDS PUBLIC TRANSPORT
THE CITY OF CAPE TOWN RESERVES THE RIGHT TO MAKE THE FINAL DECISION REGARDING ADMISSION TO THIS SERVICE.
PLEASE USE CAPITAL LETTERS ONLY AND TICK APPLICABLE BLOCKS.
PLEASE NOTE THAT PARTIALLY COMPLETED FORMS WILL NOT BE ACCEPTED.
If you were not physically disabled would you have been able to use normal public transport?
Yes
No
Are you physically able to board and leave normal public transport?
Yes
No
Do you require transport daily between your home and work?
Yes
No
1. APPLICANT DETAILS
Title
Mr
Mrs
Ms
Dr
Rev
Prof
Male
Female
Surname
First name(s)
Physical (home)
address
Code
Postal address
Code
Home no.
Code
No.
Work no.
No.
Fax no.
Code
No.
Cell no.
Code
E-mail address
ID no.
Passport No.
Emergency contact person
Contact no.
Code
No.
Relationship
2. EMPLOYMENT DETAILS
Name of company/employer
Physical address
Code
Contact person
No.
Tel no.
Code
3. DOCTOR/HEALTHCARE/REHABILITATION PROFESSIONAL
Title
Mr
Mrs
Ms
Dr
Rev
Prof
Name
Work no.
Code
No.
Fax no.
Code
No.
Cell no.
E-mail address
Practice no.
PLEASE SEE OVERLEAF
4. DISABILITY
Please state the disability preventing you from accessing mainstream public transport
Is your disability temporary or permanent?
Temporary
Permanent
Don’t know
Manual wheelchair
Electric wheelchair
Power scooter
Service animal
Walking aid
Crutches
Cane
Quad cane
Other
None
Will you require a personal care attendant to accompany you during travel?
Yes
No
Have you completed any mobility instructions?
Yes
No
Please select the mobility aids you use. In progress
N/A
5. DECLARATION
In my opinion, I am physically unable to board and leave existing normal public transport. I confirm that:
I am fit and able to travel on this special needs public transport service.
I have read, am fully aware of and accept as binding the Conditions of Carriage.
Note: This application will only be processed if both these boxes are checked.
Applicant’s signature
Date Y Y Y Y M M D D
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