citizencard-web-application-form-jan-2024.pdf

Parent/Guardian Signature:

Cardholder Signature:

Referee Signature:

Date:

Applicant Signature:

ATTACH

ONE

PHOTO

HERE

Applicant Declaration (please use CAPITAL LETTERS; all sections must be completed in full)

Referee Declaration (must meet criteria overleaf)

Payment and Parental Consent (if applicant is under 16)

REQUIRED IF APPLICANT IS UNDER 16: I consent to this application for a CitizenCard.

Route 1: Referee Validating Document(s):

Route 2: Referee Verifying From Official Records:

For more information please visit

citizencard.com

Title

Surname

House No.

Street

Town/City

County

Home Tel.

E-mail address

Title

Job Title

Name of Organisation

Professional Registration No. if applicable

Work address

Work Tel. No

Work E-mail Address

First Name Surname

Postcode

Ext.

Given Names

Date of Birth

Postcode

Mobile

Male

Gender:

Female Other

House Name

Cardholder name as it appears on card

Card Expiry Date

Card Number

Amount (£)

Mother Father Guardian

Name

The applicant is known to me and I have written on a copy of their original

document confirming their identity “

I certify that I have seen the original of this

copy and that it matches the name and date of birth on the CitizenCard application

form

” adding my name, signature and the date.

The applicant is unknown to me and I have written on a copy of their original

photographic ID document confirming their identity “

I certify that I have seen

the original of this copy and that it matches the name and date of birth on the

CitizenCard application form

” adding my name, signature and the date.

I certify that the applicant is known to me and their full name and date of birth,

as declared above on this application form match the records held at this office/

organisation.

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

I understand that providing false information is a criminal offence (Fraud Act

2006) and I consent to being contacted at my workplace to confirm the information

supplied and acknowledge that the applicant has consented to me confirming their

personal details

(found in the Applicant Declaration above)

I have written on the reverse of one photo “

I certify that this is a true likeness of

[applicant’s name]

” followed by my name, signature and the date.

I have written on the reverse of one photo “

I certify that this is a true likeness of

[applicant’s name]

” followed by my name, signature and the date.

I understand that providing false information is a criminal offence (Fraud Act

2006). I consent to being contacted at my workplace to confirm the information

supplied and acknowledge that the applicant has consented to me confirming

their personal details

(found in the Applicant Declaration above)

STANDARD APPLICATION:

I enclose standard payment of £18.00

21 days after receipt of application (subject to verification)

URGENT APPLICATION:

I enclose urgent payment of £35.00

1-2 Working days after receipt of application (subject to verification)

POSTAL ORDERS payable to CitizenCard

DO NOT SEND CASH OR CHEQUE

I understand that payment covers the cost of processing this application. I am not buying the card, which remains the

property of CitizenCard Limited and that the card may not be lent to, or used by, anyone other than myself.

I enclose 2 colour photos (45x35mm), one of which is signed by my referee.

(Route 1 only) I enclose a photocopy of an original document confirming my identity signed by my referee.

I consent to the referee (named below) confirming my details when contacted by CitizenCard at their workplace.

I consent to being contacted by CitizenCard e.g. regarding replacement cards, market research and card offers:

by email including discount offers by SMS by post

I acknowledge that providing false information is a criminal offence (Fraud Act 2006). I understand CitizenCard will not issue a card unless all

requirements for card issue have been met (full T&Cs at citizencard.com/terms-and-conditions).

CitizenCard WEB Jan 2024

D M Y Y Y Y D

REMEMBER THE FRAUD ACT 2006:

“Providing false information is a criminal offence”

ROUTE 1: Referee Validating Document(s):

ROUTE 2: Referee Verifying From Official Records:

Payment, Parental Consent & Photo Guidelines

Notes For The Referee:

Referee Verification Criteria:

The referee must:

• work in a recognised profession where their business details can be verified and are

published/advertised in online professional business directories.

• be contactable at their registered business address via email and on their work

telephone number during office hours i.e. Mon-Fri, 9.00 - 17.00 (we will call them).

• not be related to you or in a personal relationship with you (cannot be a guardian,

foster carer, spouse, civil partner, fiancé, boyfriend/girlfriend).

• not live with you.

1. Choose your referee

(visit citizencard.com/route-1-referees for all information).

They must be professionally employed and meet our criteria, for example:

2. The referee must complete the Referee Declaration and countersign one photo.

3. Take this form, together with one of the original documents below and a photocopy

of that document, to your referee who will countersign this form, one of your photos

and the photocopy of your document. You must show the referee one of the following:

If the referee is unknown to you, you must use a photographic ID document instead

(Passport, Driving Licence, EU National ID Card).

4. If you have legally changed your name and the document shows your previous

name, please show your referee the original name change document(s) and have them

countersign the photocopies and include this when you send us your application. We

accept change of name deeds, marriage certificates, gender recognition certificates

and court orders as proof of change of name.

• Adoption Certificate

• Biometric Home Office Photo ID

• Birth Certificate

• Certified Copy of a Birth Certificate

• Disclosure and Barring Service

Certificate (DBS)

• European National ID Card (must bear a

recent likeness to you)

• Global or European Health Insurance

Card (GHIC/EHIC)

• Gender Recognition Certificate

• Accountant

• Bank/Building Society Official

• Barrister

• Chairman/Director/Manager of a Limited Company

• Chemist/Pharmacist

• Civil Servant (permanent)

• Councillor: Local or County

• Dentist

• Director/Manager of a VAT registered charity/

company

• Doctor (medical)

• Funeral Director

• Immigration Adviser

• Legal Secretary

• Member of Parliament

• Minister of Recognise Religion

• Nurse (NMC)

• Officer of the Armed Forces

• Optician

• Personal Licence Holder

• Police Officer

• Salvation Army Officer

• Social Worker

• Solicitor

• Police Officer

• Teacher/Tutor/Lecturer

• Trade Union Official

• Ministry of Defence Form 90 (Defence

Identity Card)

• NHS Medical Card

• Passport (UK or International; must

bear a recent likeness to you)

• Photo Driving Licence (UK or European;

must bear a recent likeness to you)

• Proof of Age Standards Scheme Card

• Marriage Certificate (which states

applicant’s date of birth)

• UK Naturalisation Certificate.

1. Choose your referee - they must be professionally employed, know you and be able

to confirm your details against their official records held at their place of work.

Permitted list of referees matching details against their official records:

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

• your Teacher / Tutor / Head of Year / Administrator / Careers Adviser at your

School, College or 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

• your Jobcentre Plus Work Coach

• your Immigration Adviser registered at the Office of the Immigration

Commissioner

• if you are employed with any of the above referees, they can verify your identity

from their personnel records

• if you are employed by a Public Authority / Government, your employer 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

• if you are employed by a UK business that has more than 250 staff, your

employer can verify your identity from their personnel records.

2. Take this form to your referee who must countersign this form and one of your

photos.

3. The referee must certify that your name and date of birth match the official records

held at their workplace.

• Make sure you meet our verification criteria and are working in one of the

occupations listed on this form or online.

• You must be willing to tick all of the boxes in the Referee Declaration for the Route

that has been chosen.

• You must complete the Referee Declaration in full, including your signature.

• You must write on the reverse of one of the photos

‘I certify that this is a true

likeness of [name]’

followed by your full name, signature and the date.

• If a document has been provided, check the details match the details provided in

the Applicant Declaration. The applicant needs to show you the original document

confirming their identity in person. Write on the photocopy of the document

’I certify

that I have seen the original of this copy and that it matches the name and date of

birth on the CitizenCard application form’

followed by your full name, signature and

date.

• CitizenCard will contact you through your workplace to verify the information

provided.

• Standard applications cost £18.00 - 21 days processing (subject to verification

checks) - card sent by 2nd class post; Urgent applications cost £35.00 - 1-2 working

days processing (subject to verification checks) - card sent by next day delivery.

• Payment can be made by card or by enclosing a Postal Order made out to

‘CitizenCard’. Please DO NOT enclose cash or cheques.

• We recommend you send your application via recorded delivery.

• Please Note: Payment is made for Application Processing and Validation Service.

If you complete the Application process successfully we will issue you with a

CitizenCard, subject to conditions of use, which remains at all times Our legal

property. If an application fails, payments will not be refunded.

• If the applicant is under 16, a parent/guardian must consent to the application and

fill out the Consent area at the bottom of the form overleaf.

• For more information please visit citizencard.com

• If your application is successful and you are issued a card, you will have access to

SimpleSavings, our online discount platform, where you can save money on everyday

essentials with your favourite big brands. Visit citizencard.com/discounts

Photo Guidelines: for full photo guidelines visit citizencard.com/photo-guidance

PLEASE POST YOUR COMPLETED APPLICATION BY RECORDED DELIVERY TO:

CitizenCard Ltd.

7 Prescott Place

LONDON

SW4 6BS

The CitizenCard Scheme is operated by CitizenCard Ltd

a non profit company limited by guarantee in England &

Wales Nº 366-99-49 Registered Address:

7 Prescott Place London SW4 6BS

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