EMAIL BOOKING REQUEST

Please complete this form on your computer and then email as an attachment to Dar.Reservations@tfl.gov.uk
You can use the tab key + shift key or mouse pointer to move forward and backward between the fields you have to fill in
It is important you fill in all fields for us to correctly process your booking, press the F1 key for advice on any field for more information. Please complete this form on your computer and then email as an attachment to Dar.Reservations@tfl.gov.uk
You can use the tab key + shift key or mouse poin ter to move forward and backward between the fie lds you have to fill in . It is important you fill in all field s for us to correctly process your booking, press the F1 key for advice on any field for more information .

CUSTOMER DETAILS
Customer Number:       Title:      
Surname:       Forename:      
Home Address:       Post Code:      
Email:       Mobility Aid: PLEASE SELECT...
OUTWARD
Date of Travel:      Trip Purpose: PLEASE SELECT...
Pick up Address
      Post Code:     
if not from home:
Pick up Time (24 Hour Clock):      Start Time (24 Hour Clock) appointments, meetings, ticketed events…etc:      

Will you be travelling with a companion? Yes No Will you be travelling with children? (number of children):  
If travelling with child/children please check the boxes of the appropriate age/s:
Under 12 months 1 – 4 years 5 – 11 years 12 – 15 years

Destination Address:       Post Code:     

If you require a certain amount of time at your destination, length of stay e.g. shopping, please state in hours and minutes
and do not request a return time:
     
RETURN
Return Date of Travel if different from above:      
Return Pick-up Address
if different from       Post Code:      
destination above:
Return pick up time (24 Hour Clock):     

Will you be returning with a companion? Yes No Will you be returning with children? (number of children):  
If returning with child/children please check the boxes of the appropriate age/s:
Under 12 months 1 – 4 years 5 – 11 years 12 – 15 years
Return Destination
      Post Code:     
Address if not home:
If we are not able to find a journey we can place your request on our stand-by list: PLEASE SELECT YOUR PREFERENCE...

You may not always be allocated a Dial-a-Ride vehicle please select below the alternative vehicles that you are able to travel in
Saloon Car People Carrier Black Cab
COMMENTS
Please make any additional comments that feel are important for us to successfully manage your booking request:
     

DECLARATION
Please note that this form and the personal data contained in it will only be used for the sole purpose of providing registered customers with the Dial-
a-Ride service, if your personal details differ from those that we hold in our records we may contact you to confirm them and update our records if
necessary. This is in accordance with our obligations under the Data Protection Act 1998. If you have completed this form for yourself please check
the box in the declaration below. If you have completed the form on behalf of a customer please check the appropriate box, print your name and
clearly state your relationship to the customer. It is important that you do so as we are unable to process your booking without this.
Please note that this form and the personal data contain ed in it will only be used for the sole purpose of providing registered customers with the Dial-a-Ride service , if your personal details differ from those that we hold in our records we may contact you to confirm them and update our records if necessary. This is in accordance with our obligations under the Data Protection Act 1998 . If you have completed this form for yourself please check the box in the declaration belo w . If you have completed the form on behalf of a customer ple ase check the appropriate box, print your name and clearly state your relationship to the customer. It is important that you do so as we are unable to process your booking without this.

I declare I am the customer and the information given above has been requested by me:

Or I am requesting this booking on the customers behalf:

Print Name:      Relationship:     

End of Form Thank you for using Dial-a-Ride.