the application form

Application Form
YP12CW
Please complete the appropriate sections and boxes electronically or print off and write CLEARLY and in BLOCK CAPITALS.
Email is the most environmentally-friendly way for you to hear about Railcard news and any of our great offers.
Email
Title
Mr
Mrs
Miss
Ms
Other
Please specify
Date of Birth
D D
MM
Y Y Y Y
(please select as appropriate)
First Name
Surname
Home Address
Town
Postcode
INC
CODE
Telephone
Occupation
Mobile Phone
School/FE student
Part-time student
HE/University student
Full-time employed
Part-time employed
Not in employment
Mature student
(please select as appropriate)
Renewals
Are you renewing your
16-25 Railcard?
Yes
Expiry date of
existing Railcard
D D
No
MM
If so, what is your existing Railcard Number?
Y Y Y Y
How many 16-25 Railcards have you held in the past?
Mature Students Only
All students aged 26 years and over, in full-time education must also complete this section. Your tutor, head tutor, head of department or University/College administration staff member needs to
complete and sign below: I confirm that the applicant is a student attending University/College for over 15 hours per week, at least 20 weeks a year. I have signed and stamped the photo on the back.
University/College Stamp:
Print Name
Signature
Position
Name of University/College:
Telephone
Declaration - to be completed by all applicants
Before signing this declaration, it is important that you have read, understood and agree to the Terms and Conditions of the Railcard, together with the National Rail Conditions of Carriage. Copies of the National
Rail Conditions of Carriage are available online at nationalrail.co.uk/nrcc. I have read, understood and agree to the Terms and Conditions of the Railcard. I confirm that the details I have provided are
correct and I am aged between 16 and 25 years or a mature student.
Signature
Date
D D
MM
Y Y Y Y
On behalf of the Train Companies, ATOC Ltd collects and processes personal information for the purpose of sales analysis and market research. ATOC Ltd is registered in the UK under the Data Protection Act 1998 as a
Data Controller. We will contact you when your card is close to expiry, providing we have valid contact details. From time to time your personal details may be used to send you relevant information as described below.
If you do NOT wish to receive such information, please tick the relevant boxes.
I do NOT want to receive:
Railcard information and offers
Train Company offers and other rail-related services
by Mail
by Email
by SMS
We would also like to share your information with third parties so that they may send you information about their products and services.
If you do not want to receive this information by post, please tick here
If you do want to receive this information by email or SMS, please tick here
FOR ISSUING OFFICE USE ONLY
Station or Travel Agent Stamp:
New Railcard No.
Photocard No.
Date of Application
Card Expir y Date
D D MM Y Y Y Y
D D MM Y Y Y Y
Please remember to also complete the ‘Receipt’ section on this leaflet.
Station/Agency NLC or Code No.
Please ensure that the issuing station/National Rail licensed Travel Agent fills in this section for you.
16-25 Railcard Receipt
This form acts as your receipt of purchase for your 16-25 Railcard and must be shown should you need to get a replacement Railcard. It’s best to keep this separate from your Railcard.
Station or Travel Agent Stamp:
Railcard Holder’s Name
Railcard No:
Expiry Date:
D D M M Y Y Y Y