Name...................................................................................................
Address..............................................................................................
..........................................................................................................
............................................................................................................
Postcode...........................................
Telephone........................................
Date of Birth.....................................

If applicable, please indicate the nature of your incapacity e.g. Arthritic or partially sighted, walking difficulties etc below.
.......................................................................................................................
.......................................................................................................................
...........................................................................................................................
........................................................................................................................
To aid our drivers please tick if any of the following apply to you

Use a wheelchair......  Manual.........      Electric........       Extended........
Can you transfer from a wheelchair......
Use a walking aid......
Travel with an escort......
Bring a guide dog......

Please nominate a friend/relative who can be contacted in the event of us being unable to contact you, or if you are not on the telephone.
Name..........................................................
Telephone....................................................

Ethnic Origin           Please tick
British..............
Other................      Please state country of birth...................................................

I declare that the information given is correct and I understand that the service is subject to availability on a first come first served basis.
I also agree to my details being held on a computer and in manuscript form on the company premises.

Signed.....................................................      Date.......................  

If you are interested in becoming a member, please print out this page, complete the details and send the form together with your one-off membership fee of £8.00 to our Offices at Unit One, Flitch Industrial Estate, Chelmsford Rd, Dunmow, CM6 1XJ