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 *

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 and I agree to abide by the terms and conditions as set out in the Ely & Soham Association for Community Transport conditions of hire, and I understand that any breach of these conditions may result in being expelled from membership. I understand that Ely & Soham Association for Community Transport does comply with the Data Protection Act and I consent toEly & Soham Association for Community Transport holding the above information about me.