(Please complete this box ONLY if you are renewing your membership)
TITLE *
FORENAME *
SURNAME *
ADDRESS 1 *
ADDRESS 2
ADDRESS 3
CITY *
COUNTY *
POSTCODE *
TELEPHONE *
EMAIL *
DATE OF BIRTH *
CONTACT NAME *
RELATIONSHIP *
Do you have a Cambridgeshire County Council bus pass? *
Yes
No
If Yes:
BUS PASS NUMBER
BUS PASS EXPIRY DATE:
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)
Electric wheelchair
Manual wheelchair
Folded manual wheelchair
Scooter
Shopping trolley
Walking frame
Helping dog
Child's buggy
Other (please state below)
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.