APPLICATION FOR ATTENDANT WORDING ON RAIL STAFF TRAVEL NATIONAL CARD/PASS

This form must be completed by the primary cardholder which is usually the employee or the widow/widower. Adding attendant wording to a national card/pass allows the cardholder who has a card to have someone travel with them at the same rate. This cannot be added to International Travel facilities.

* - Mandatory Field

Employee/Widow(er) details

Title*

First Name*

Last Name*

NI Number*

Date of Birth*

Address 1*

Address 2

Town*

County

Postcode*

Home Phone

Mobile No

Email*

Work Email

Card Holder Requiring Attendant Wording

Title*

First Name*

Last Name*

Eligibility Code**

Date of Birth*

Attachment upload*
(as required)

**Eligibility codes (select value in box above)
1	Receive Disability Living Allowance or Child Disability Payment at either: the higher or lower rate for the mobility component, or the higher or middle rate for the care component Supporting documentation A copy of the award letter showing receipt of Disability Living Allowance or Child Disability Payment in the past 12 months
2	Receive Personal Independence Payment or Adult Disability Payment at any rate Supporting documentation A copy of the award letter showing receipt of Personal Independence Payment or Adult Disability Payment in the past 12 months
3	Have a visual impairment Supporting documentation A copy of the Certificate of Visual Impairment (CVI), BP1 Certificate (Scotland) or BD8 Certificate for being registered blind or partially-sighted
4	Are registered as deaf or use a hearing aid Supporting documentation A copy of the front page of your NHS battery book or a copy of your dispensing prescription from a private hearing aid supplier
5	Have epilepsy and either have repeated seizures even when receiving drug treatment; or are currently prohibited from driving Supporting documentation A copy of your Exemption Certificate for epilepsy medication and a photocopy of your prescription for drugs. Residents of Scotland and Wales and those aged 60 and over in England, where a Medical Exemption Card is not required, you need only supply a photocopy of your prescription or A copy of your Exemption Certification for epilepsy medication and a photocopy of your letter from the DVLA telling you that you are unable to drive
6	Receive Attendance Allowance, Severe Disablement Allowance or Pension Age Disability Payment Supporting documentation A copy of the award letter
7	Receive War Pensioner's Mobility Supplement Supporting documentation A copy of the award letter
8	Receive War or Service Disablement Pension for 80% or more disability Supporting documentation A copy of the award letter
9	Are buying or leasing a vehicle through the Motability scheme Supporting documentation A copy of the leasing or hire-purchase agreement, dated within the past 12 months

Declaration by the primary cardholder*

By checking this box:By submitting this form:

I confirm that all details provided are correct and I have supplied any required documentation.
I understand that I am responsible for the correct use of mine and my attendants rail staff travel facilities and understand that such use is subject to the Conditions of Issue and Use which can be found at www.raildeliverygroup.com/rst/conditions-of-issue-and-use.
I understand that an attendant can only benefit when travelling with me on the same journey and they cannot use it when I am not travelling.
I further understand that Rail Staff Travel’s privacy information is available online at www.raildeliverygroup.com/rst/rst-privacy and that I have read it and have made my attendant aware of it.

Signed by Prime Cardholder (Employee or Widow):

Date:

Form - AttendantRequest - XX45 - This form is not valid for use after 31/03/2025

Once completed save the form with a filename of “YourLastname_Your Firstname_XX45_ddmmyyyy” – where ddmmyyyy is the date that you send the form to RST). Then submit via email to rst@raildeliverygroup.com or your normal rail staff travel facilities contact point

APPLICATION FOR ATTENDANT WORDING ON RAIL STAFF TRAVEL NATIONAL CARD/PASS

**Eligibility codes