CCT logophoto of one of our minibuses

MEMBERSHIP APPLICATION

Click here to download a form to print, fill in by hand and send with your subscription.


Alternatively, you can fill in the form below then either phone to pay by credit card or post a cheque to us.

* = mandatory field

e.g. Mr / Mrs / Ms / Dr











To ensure that we send the correct type of vehicle for you, if you normally use any of the following, then mark that checkbox and give details:

Yes;
 
                Please state its make, model, and dimensions (if known).

Yes;
 
                Please state whether manual or electric.

 
             Can you transfer from your wheelchair to a vehicle seat?

Yes;
 
                Please state whether a walking stick, frame, rollator etc.

Yes

Yes


Alternative Contact Details

On some occasions, we may need to pass on some important information regarding your booked journey. We recommend that this be a family member, friend or neighbour who can pass on this information to you during out-of-office hours.



 
e.g. husband / wife / friend / neighbour, etc.

How did you hear about Chelmsford Community Transport?
Please select one

Word of mouth;  Dial a ride;  Social Services / Carer;  Doctor / Nurse / Clinic;
Leaflet;  Media;  Website;  Group or Association;  Other;

If 'other', please give brief details:

Please mark the checkboxes below and inform us whenever you experience any changes in your mobility or health

I declare that the information given on this form is correct and I understand that the service is subject to availability on a first-come, first-served basis.

I agree to my details being held in manuscript form and in a computer on the company's premises.

Captcha This is necessary to defeat hackers.

The completed form will be sent to the Chelmsford Community Transport office. A copy will be e-mailed to you for your records.

After sending the form, you need to pay the annual subscription.
Either telephone the office and quote your credit or debit card details, or post a cheque to us.