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DERBYSHIRE

Derbyshires travel, discount and library card for 11 to 18s

Application form
IMPORTANT NOTES: Please note that this application form is ONLY for young people who are unable to get their application verified by their school or college. This may be because you: are no longer in education (and have not reached your 17th birthday) are home educated need an urgent replacement card during school/college holidays attend a school or college outside of Derbyshire. There are some exceptions. Please contact Call Derbyshire 08456 058 058* for advice
*An average 3 minute call costs 10p for BT customers. Charges from other suppliers vary.

BX
B_line1 APPliCAnTs:
I am aged between 11 and 13. If you are 11 you must be in Year 7, not Year 6. Please complete Parts A and C only.

B_line2 APPliCAnTs:
I am aged between 14 and 18 and in full time education. You can have a b_line card until your 19th birthday if you are in full-time education. Please complete Parts A and B only.

CHECKLIST
Before you send in your application, please make sure you have enclosed the following, where applicable. completed application form. colour passport-style photo not your school photo printed on photographic paper with your name written on the back, then signed and dated by your verifier. It must be a good likeness of you. No hats or sunglasses. a photocopy of your identity document (not the original) signed and dated by your verifier (b_line2 only). your expired b_line card or a photocopy (if it has not yet expired) if you are applying for a free replacement card. cheque for 5 made payable to Derbyshire County Council if applying for a replacement for a lost or damaged card. if you are under 16, your form must also be signed by your parent or legal guardian. Send this form to: b_line applications (BX), Derbyshire County Council, County Hall, Matlock, Derbyshire De4 3AG. Please allow up to 3 weeks to receive your new b_line card. It will be sent to your home address.

*iMPORTAnT nOTes ABOUT VeRiFiCATiOn


If you are asked to verify this application form you must have no family connection with the applicant and be one of the following: Careers adviser or librarian Dentist, doctor, optician, pharmacist or vet Barrister, judge, magistrate or solicitor Accountant or bank manager Councillor, MP or MEP Minister of other official of religion Police officer or police civilian staff Trading standards or environmental health officer Lecturer, social worker, teacher or tutor. if you DO nOT know the applicant they must show you one of the following approved forms of PHOTO iD: passport, photo driving licence, immigrant ID card. You must check the original ID and then sign a photocopy. The signed photocopy must be sent to us with this application form. if you DO KnOW the applicant they must show you one of the following approved forms of iD: passport, photo driving licence, immigrant ID card, birth certificate, NHS card, National Insurance card. You must check the original ID and then sign a photocopy. The signed photocopy must be sent to us with this application form. Please note you are not obliged to act as a verifier. However, you must be willing to be contacted by telephone by county council staff. This is a requirement of the proof of age PASS scheme.

is YOUR APPliCATiOn FOR? (tick one)


A first b_line1 card (free) A first b_line2 card you must be 14 or within one month of your 14th birthday (free) A replacement for a lost or damaged card (5) A replacement for a b_line2 card that has expired or is due to expire in the next month. Please enclose your old card or a photocopy (free)

PART A All applicants


(BlOCK CAPiTAls)

PART B b_line2 applicants


(BlOCK CAPiTAls) You need to ask an adult who is not a member of your family to verify your application by signing the back of your photograph and the statement below.

APPliCAnT DeTAils
If you are 17 or 18 (Up to 19th birthday) you must be in full time education to qualify for a b_line card. To help us get a b_line card to you as quickly as possible, please complete all parts in BlOCK CAPiTAls. This is important otherwise your application may be returned and your b_line card will be delayed. Surname: First name: Home Address:*

TO Be COMPleTeD BY THe VeRiFieR


Before you verify this application please read the iMPORTAnT nOTes ABOUT VeRiFiCATiOn overleaf* Surname: First name: Occupation: Work name and Address:

Postcode: Home telephone number with code (not a mobile): Daytime telephone number for your parent/carer (not a mobile):

Work Postcode: Work Phone number (not home or mobile) include code: Name of Applicant: I confirm that: I have signed and dated the reverse of the photograph to declare that it is a true likeness of the applicant. I have checked and countersigned a copy of the original document shown to me. (This must be a form of a photo ID on the list below if the applicant is not known to you). The date of birth written in Part A matches the date shown on the original document I have seen. I understand that providing false information is a criminal offence. I understand that I will be contacted by telephone to confirm the details supplied. Signature of verifier: Date:

Date of birth: DAY DAY MTH MTH YEAR YEAR School: Signature of applicant: Date: I understand that providing false information is a criminal offence. *You must live in Derbyshire (including Derby City) to qualify for a b_line card.

PART C Under 16s only


if you are under 16 your parent or legal guardian must complete this section. I consent to this application for a b_line card. Please ensure you sign the back of the photo. Full name of parent/guardian (BlOCK CAPiTAls): Signature: Date:

Data Protection
Any personal information supplied to the county council may be stored on computer. Your details will be protected and will only be used for the purposes of the b_line scheme.

DERBYSHIRE

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