First Name

Last Name

Will the person named above, be booking the tickets? *

Yes

Telephone Number

House / Flat Number

Street

Town

Post Code

Representative First Name

Representative Last Name

Representative email address

Representative Telephone Number

Representative House / Flat Number

Representative Street

Representative Town

Representative Post Code

Type of application *

I am in receipt of the higher rate of the Disability Living Allowance - Care or Mobility Component, the higher rate of Attendance Allowance, the enhanced rate of the Personal Independence Payment - Daily Living or Mobility Component, holds a Certificate of Visual Impairment or holds a Nimbus Access Card with a +1 symbol and would like to apply for a complimentary seat for my Essential Companion.

I am in receipt of the middle rate of the Disability Living Allowance - Care Component, the standard rate of the Personal Independence Payment - Daily Living Component or the lower rate of Attendance Allowance and would like to apply for a 50% ticket price reduction on an adult ticket for my Essential Companion.

Evidence of entitlement *

Which of the following preferences would you like us to record to assist in future bookings:

Aisle Seat

Wheelchair space

Large wheelchair space

Stalls seat

Terrace Seat

Hearing Loop

Other

Consent for storing submitted data *

Yes, I give permission to store and process my data.

Essential Companion Scheme Individual Application Form

Essential Companion Scheme Individual Application Form