Group Services Affiliation Group welcome pack Login Username or email address * Password * Log in Remember me Lost your password? Register Email address * Password * Register You need to login or register first before completing this form. Twitter Name of Organisation Contact name Title Mr. Ms. Mrs. First name Last Name Address City County Postcode Tel. E-mail Fax. Name and address to which invoices should be sent. (if different from above) Invoice Name Invoice Address Invoice Postcode Invoice Tel. Invoice Fax. Names and addresses of organisation members or individuals authorised to make bookings. Name Name Address Address Postcode Postcode Tel. Tel. Annual User Registration (please tick one of the following boxes): Statutory Organisations - £100.00 Including VAT Yes Funded Groups - £50.00 Including VAT Yes Non-Funded Groups - £30.00 Including VAT Yes Pro rata charge apply for mid year affiliations. Status (Please answer all questions) Are you a group/individual listed below: Our vehicles may only be used by groups involved in one or more of the activities listed below. (Please tick those with which your group is concerned) A Voluntary group?…… Yes No A Community group?…… Yes No A Statutory group?…… Yes No A Registered charity?…… Yes No Education Yes Religion Yes Recreation Yes Social Welfare Yes Please state No. Adults or children with disabilities and older people with mobility needs can affiliate to MCT’s Individual Transport Service: Yes No Other activities of benefit to the community or individuals? (Please specify): Please read and sign the following declaration: The above organisation agrees to abide by the terms and conditions as set out in the Merton Community Transport vehicle user agreement and the affiliation pack. We understand that any breach of these conditions may result in our group being removed from MCT’s affiliation user list. All information supplied is correct, and I am authorised to make this commitment on behalf of the above organisation. Name Position Signature Date Having completed this form, including the monitoring details, please return it with a cheque for the appropriate amount made payable to: Merton Community Transport. Merton Community Transport is committed to the promotion of equality of opportunity in the provision of its services. In order to ensure that all affiliated sections of the community benefit from these services, we would be grateful if you could provide us with the following details regarding you as an individual /organisation and its members and users of MCT services. Should you require any assistance with the completion of this form, please phone MCT’s offices on 020 8648 7727. What are the main aims of your organisation or your transport needs as an individual? What do you intend to use our vehicles for? Vehicle use, MPV or Minibus? How many members does your organisation have or individual family members? Please give an estimate of the numbers of your members in each category listed below! Ethnicity: Black: Asian: White British: White European Others Age Range: 0 - 5 5 - 16 17 - 60 61 - 70 70+ Others: Low income: People with disabilities: WC user: Female: Male: How many of your members or individuals who will benefit from MCT’s services live in the following areas: (please use map below for guide) 1. Village, Raynes Park, Hillside, Dundonald 2. Durnsford, Trinity, Abbey, Merton Park 3. Colliers Wood, Lavender, Graveny, Figge’s Marsh 4. Ravensbury, Phipps Bridge, Longthornton, Pollards Hill 5. West Barnes, Cannon Hill, Lower Morden, St Heliers This affiliation will not be processed until the payment for this application has been received. Payment can be made by cash or cheque. Please make cheques payable to Merton Community Transport. We cannot process credit or debit cards.