Membership No:

(Please complete this box ONLY if you are renewing your membership)

Your Contact Details

TITLE *

FORENAME *

SURNAME *

ADDRESS 1 *

ADDRESS 2

ADDRESS 3

CITY *

COUNTY *

POSTCODE *

TELEPHONE *

EMAIL *

DATE OF BIRTH *

In case of an emergency who should we contact?

CONTACT NAME *

TELEPHONE *

RELATIONSHIP *

Cambridgeshire County Council bus pass

Do you have a Cambridgeshire County Council bus pass? *

Yes

No

If Yes:

BUS PASS NUMBER

BUS PASS EXPIRY DATE:

What is the main reason that you need to use this service? *

Tick all that apply

The local bus timetable does not meet my needs

I live too far from the bus stop

I find the local buses physically too difficult to use

No bus service available

I am disabled and cannot use the public bus service

Other reason (please state below)

When travelling with ESACT, would you like to bring with you any of the following?

Tick all that apply

Electric wheelchair

Manual wheelchair

Folded manual wheelchair

Scooter

Shopping trolley

Walking frame

Helping dog

Child's buggy

Other (please state below)

Declaration *

I wish to apply for membership of Fenland Association for Community Transport and I agree to abide by the membership terms and conditions. I understand that any breach of these conditions may result in being expelled from membership.

This information will be held securely and will be accessed by employees of FACT for services you require. Your information will not be shared with any third parties and you have the right to request a copy of the information that we hold on you. Please tick box to confirm you have read the above statement and agree.