v TRANSPORT DEPARTMENT DIAL-A-RIDE PUBLIC TRANSPORT (Cc a Town | sex ase |sTHOKAPSTAD THIS CITY WORKS FOR YOU APPLICATION FOR SPECIAL NEEDS PUBLIC TRANSPORT THE CITY OF CAPE TOWN RESERVES THE RIGHT TO MAKE THE FINAL DECISION REGARDING ADMISSION TO THIS SERVICE, PLEASE USE CAPITAL LETTERS ONLY AND TICK APPLICABLE BLOCKS. PLEASE NOTE THAT PARTIALLY COMPLETED FORMS WILL NOT BE ACCEPTED. tyr vee mt sc ied wold ou hve be ese mma iictonane? — (QYfes (No Ae you salable to boar and ave roma pbc nso? ws Wao Doyo equi raspart dalyetween our and wt? we ie 1. APPLICANT DETAILS Title Me Mes Ms v br Rev Prof Male fy Sumame Raa Fistramels) — GuAHIDA, Prysical (tome) |g SNIPE COURT, NEW HORIZONS, PELICAN PARK, CAPE TOWN. address Code 7941 Postal ast Ce vome no. Code We Wono. Code Wo faim. Coe a cello ones Emalesses yaseen21@live.coza nies 670624.0136 081 Pesala Emergency contact pesson AISHA, Contact no. Code | 27 No. ( 084 039 5352 Relationship _ DAUGHTER 2. EMPLOYMENT DETAILS Name of companyfemployer Physical address ( Code Contact person Tel, Code No. 3. DOCTOR/HEALTHCARE/REHABILITATION PROFESSIONAL Tle =m Mes Ms or Re Pro Name GROOTESCHUUR HOSPITAL Workna, Cage Na Faxno. Coe No, cana Email adress Practice no. PLEASE SEE OVERLEAF4. DISABILITY Please state the disability preventing you from acessing mainstream public transport RHEMETOID ARTHERITIS |s your disabiliy temporary or permanent? Temporary Permanent Vv Don't know Wil you requir a personal care attendant to accompany you during travel? Yes No) 5. DECLARATION In my opinion, | am physically unable to board and leave existing normal public anspor. confirm that | am ft and able to travel on this special needs public transpor service U have read, am fully aware of and accep as binding the Conditions of Carage Note: This application wil only be processed if both these boxes are checked. Applicants signature s Lyra hj date (20.1 18 10.5 0 4