Application for Priority Seat Card

Please use BLOCK CAPITAL letters and c omplete all fields.

A. Personal Details (to be c ompleted by Applicant)
Title

Mr

Mrs

Ms

Miss

Other

Surname
First Name/s
Postcode
Home address

Town
County
Telephone

Home/mobile
Work

Personal email
Date of birth*

M M

*A pplicable fo r applicatio ns fo r o ver 65's o r where applicatio n is made fo r acco mpanying an infant (infants date o f birth should be inserted)

Due date**

M M

M M

**If applying due to pregnancy

Date of rec overy***

***fo r tho se with a tempo rary impairment please indicate the expected date o f reco very as confirmed by yo ur do cto r in the suppo rting do cumentatio n

Please indic ate why you are applying for the priority seat c ard:
Medic al c ondition/Disability

Over 65

Pregnant

Travelling with an infant

B. Details of regular journeys and type of ticket (to enable Southern to establish
where the scheme is being used and is most applicable)
Usual tic ket type held:

Daily

Weekly

Monthly

Annual

Freedom Pass

Please enter your local station:

Do you make a regular journey?

Yes

No

If yes, please fill in the origin and destination of your regular journey
Origin Station
Destination
Photo c ard no:
I confirm that the details I have given on this form are c orrec t and ac curate and
understand that this applic ation is subject to the Govia Thameslink Railway (GTR) terms
and conditions which I have read, understand and agree to. I also c onfirm that GTR
c an proc ess and store the details of applic ation c ontaining my sensitive personal data
and understand that my data will only be used as part of this applic ation*. GTR will not
share this information with other organisations. *please refer to page 2 for data storage details

Signature

Application for Priority Seat Card

Information submitted on this form and documentation supplied to GTR as part of this
application will be used and stored only in accordance with the Data Protection Act.
Information supplied is kept at Customer Serivices in a secure filing cabinet that only
nominated staff have access to. It is shredded six months after the applic ation.

The information on this form will only be used to contact you concerning the priority seat
card initiative.
Your details may also be used to inform you about other GTR services and initiatives in
the future. If you would prefer NOT to receive these please tick the box.

This application form should be returned to: Priority Seat Card Application, Customer
Services, PO Box 10240, ASHBY-DE-LA-ZOUCH, LE65 9EB and must be accompanied by
two passport size photos (if applying because you want a card for acc ompanying a child
you should supply the childs photo), supporting documentation listed in the criteria and
one proof of address eg copy of passport, c opy of drivers licenc e, utility bill with name
and address, copy of ID card with name and address on.

Check list for submissions - please ensure you enc lose the following in your application:
Two passport size photographs (showing head and shoulders only)
Applic ation form
Proof of address (c opy)
Proof of eligibility for card (copy - see criteria)