Online Application Form

Payment Details
Thank you. Your Personal Details have been sent to us. Your payment has been received. Please now print off this form and follow the instructions:

Application type: CitizenCard Urgent

Payment amount: £30.00
Trans. Code: {F4BE1D7F-33AB-260D-F048-B44EB293A509}
Auth. Code: citizencard21338963
Date/Time: 2017-09-09 23:42

Applicant Declaration
Title: Miss
First Name: Yazminne
Surname: Roffey

Gender: Female
Date of Birth: 19/09/1998
Card age-band:

ATTACH 
18+

House No: 54 ONE 

House Name:
PASSPORT
Street Name: Oak Close QUALITY
City: Yate (45mm x 35mm)
Postcode: BS37 5TW PHOTO
HERE
Phone:

Mobile: 07976953445
Email: ryazminne@gmail.com

• I confirm I have read and accept the CitizenCard Terms & Conditions.
• I acknowledge that providing false information is a criminal offence (Fraud Act 2006).
• I understand that payment covers the cost of processing this application.
• I enclose 2 passport quality colour photos, one of which is signed by the referee.
• I will attach to this application a copy of original document(s) confirming my identity signed
by the referee (Route 1 only).
• I consent to being contacted by CitizenCard in connection with legal, advisory and
promotional purposes.
• I understand that an incomplete application form cannot be processed.
• I consent to the referee confirming my personal details when contacted by CitizenCard.

D D |__|__
Applicant signature __________________________________________ Date |__|__ M M |__|__|
Y  Y

Please continue to the next page. You must provide a valid referee.

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continued - CitizenCard Application for Miss Yazminne Roffey, born 19/09/1998, BS37 5TW, CitizenCard Urgent

Referee Declaration
another person who is: minimum age 25, must not be a relative, retired, self employed, work from
home, be in a personal relationship with the applicant or share the same residential address
I confirm that I am acting as referee in my capacity as a professionally qualified person:
OFFICIAL
Job Title |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
STAMP
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| if available
Professional registration no./reference (if applicable) |__|__|__|__|__|__|__|__|__|__|__|__|
Title |__|__|__|__| First Name |__|__|__|__|__|__|__|__|__|__|__|__|__|
Surname |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Business Name and Address |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Post Code |__|__|__|__| |__|__|__|
Work Tel. No. Inc. Code (no mobile number) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Email |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Route 2 referee

☐ I certify that the applicant's full name, date of birth, age, gender and home address as declared on this application
form match the official records held at this organisation.

☐ I certify that the applicant is the person pertaining to our records.

☐ I have written on the reverse of one photo I certify that this is a true likeness of ...(name of applicant)... adding
my signature and date.

☐ I understand that providing false information may be a criminal offence under the Fraud Act 2006. I consent to
being contacted at my place of work to confirm the information supplied and I acknowledge that the applicant has
consented to me confirming their personal details (above).

D D |__|__
Referee signature ___________________________________________ Date |__|__ M M |__|__|
Y  Y

What to do next
1. Now please PRINT OFF this onscreen pre-filled Application Form and take it to your Route 2 referee, who must
know you and needs to confirm your details against their official records held at their place of work.
We accept only the following as Route 2 referees:

• your Doctor / Dentist / Nurse / Administrator at your GP / Dental Surgery

• your Teacher / Tutor / Head of Year / Administrator at your School / College / University
(please ensure they are available during academic holidays as they must be contactable at their place of work)
• your Social Worker
• your Certified Solicitor
• a Bank / Building Society staff member at your branch
• your Prison or Probation Officer
• if you are employed with any of the above Route 2 referees, they can verify your identity from their personnel
records
• if you are employed by a Local Authority, your employer can verify your identity from their personnel records.

The most up-to-date list of acceptable Route 2 referees can be found at www.citizencard.com/route-2-referees

2. The referee countersigns the Application Form confirming that your details match their official records.

3. You also take to your referee 2 passport-quality (45mm x 35mm) photos. The referee countersigns one as a true
likeness and both are attached to the form. For photo requirements, please visit www.citizencard.com/photo-guidance

4. You post the Application Form and the 2 photos to us at: CitizenCard, 36 Bromells Road, London SW4 0BG.
We'll then process your application. Thank you!
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