Applicant Declaration – please use CAPITAL LETTERS and BLACK INK ONLY – all sections must be completed in full

Title First Name Middle Initial(s) Male Female

D D M M Y Y (Tick box)
Surname Date of Birth
House No. House Name Age
Street
Town/City

County Postcode

Home Tel. No. Inc. Code Mobile ATTACH

E-mail ONE
Repeat E-mail
I acknowledge that providing false information is a criminal offence (Fraud Act 2006). I understand CitizenCard will not
PHOTO
issue a card unless all requirements for card issue have been met. HERE
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 the verifier and one of which is attached here.
I attach a photocopy of original ID signed by the verifier. COPY ID MUST BE SENT WITH THIS FORM.
I consent to being contacted by CitizenCard in connection with legal, advisory and promotional purposes.
I understand that an incomplete application form cannot be processed.
I consent to the verifier (named below) confirming my details when contacted by CitizenCard at their workplace.
Applicant Signature

Verifier Declaration - minimum age 25 must work as listed overleaf

Only act as a verifier if qualified (see overleaf) and if you are willing to be contacted by phone at your workplace. If you are retired, self
employed, related to the applicant or working from home you cannot act as a verifier.
Title First Name Surname
Job Title
Name of Organisation
Professional registration no./reference if applicable OFFICIAL
Work Address STAMP
Postcode
if available
Work Tel. No. Inc. Code Ext.
NO MOBILES
Work E-mail Address
You must be able and willing to tick all boxes

I The applicant is known to me personally and I have written on a

photocopy of their original ID “I certify that I have seen the original of this OR
I The applicant is not known to me personally and I have written on a
photocopy of their original photographic ID “I certify that I have seen the
copy and that it matches the name and date of birth on this application original of this copy and that it matches the name and date of birth on this
form” adding my name, signature and date underneath. application form” adding my name, signature and date underneath.

I I have written on the reverse of one photo “I certify that this is a true likeness of…” adding my signature and the date.

I I understand that providing false information is a criminal offence (Fraud Act 2006). I consent to being contacted at my workplace, by telephone,
to confirm the information supplied and acknowledge that the applicant has consented to me confirming their personal details (see above).

Verifier Signature Date D D M M Y Y

Payment & Parental Consent

POSTAL ORDERS PAYABLE TO ‘CitizenCard’ DO NOT SEND CASH OR CHEQUE
STANDARD APPLICATION allow up to 21 days I enclose standard payment of £15 (tick box)
URGENT APPLICATION I enclose urgent payment of £30 (tick box)
1–2 Working days application subject to validation

Cardholder Name Card Expiry Date M M Y Y Issue No.(Switch)

AS APPEARS ON DEBIT/CREDIT CARD

Card Valid From Date (if applicable) M M Y Y Amount £

Card No. Cardholder Signature

IF APPLICANT IS UNDER 16: Mother / Father / Guardian (delete as appropriate)
I confirm the applicant lives at the same address as myself and I consent to this application for a card.
Name

Parent / Guardian Signature Date D D M M Y Y

© CitizenCard Limited June 2014

Application valid only if all relevant sections are signed and boxes are ticked
 Fraud Act 2006: Providing false information is a criminal offence

Take your original ID to a verifier

If you do not have any ID, you can still apply
email: [email protected] for information on how to apply.
Take this form to a person aged 25 or older, in work, contactable at their workplace
and must not be a relative, guardian or carer.
They cannot be retired, self employed or work from home or live with you.
A P P L I C AT I O N F O R M
They must be a professionally qualified person, for example:
Accountant Local Government Officer
Bank / Building Society official Local or County Councillor
Barrister / Solicitor / Legal Secretary Police / Prison / Probation Officer
Chemist / Pharmacist / Optician Politician (MP / MSP / MWA / MNIA / MEP)
Civil Servant (permanent) Publican / Licensee (DPS or PLH)
Connexions Adviser Social Worker
Doctor / Dentist / Surgery administrator Teacher / Lecturer

Full descriptions of acceptable verifiers at www.citizencard.com

1 The verifier must complete the VERIFIER DECLARATION and countersign one
photo.
2 You must show the verifier one of the following original ID:
If you have queries regarding this application form, or if you do NOT have any copy ID to support
• passport • photo driving licence
your application please email us and we can advise on how you can apply without copy ID.
• national identity card • card containing PASS hologram
Email: [email protected]
• Home Office ID • UKBA Biometric Residence Permit
If the verifier knows you personally you can show them one of the following Payment, Parental Consent & Checklist
forms of ID instead:
• original or certified copy of a birth certificate 1 Standard applications cost £15. (Card posted 2nd class within 21 days).
• NHS Medical Card Enclose postal order (payable to ʻCitizenCardʼ) or pay by debit/credit card.
3 Take this form, together with one of the above original ID plus a photocopy of 2 Urgent applications cost £30. Card will be posted by Next Day Delivery 1–2 working days after
that ID, to the verifier who will need to countersign this form, one photo and the receipt (subject to validation). Pay by postal order (to ʻCitizenCardʼ) or debit/credit card.
We advise you to post application by Special or Recorded Delivery.
photocopy of the ID.
3 Please note a CitizenCard remains the property of CitizenCard Ltd. Payments are charged for the
4 If you have changed your name you will need to get a copy of the legal process of handling the application, processing and validation of data. If an application fails,
documentation (e.g. marriage certificate/deed poll) signed and dated by the verifier. payments will not be refunded. Full terms and conditions at www.citizencard.com.
4 If applicant is under 16, a parent/guardian with whom the applicant lives must consent to the
application.
Notes for verifier
Checklist
1 Check you are working in one of the occupations listed above.
2 You must be willing and able to tick all boxes.
 ifComplete all parts of the application in full, signed and dated where required. This form is invalid
any section is incomplete. Your signature consents to the application and to being contacted
by CitizenCard for legal, advisory and promotional purposes (e.g. replacement cards).
3 Complete the VERIFIER DECLARATION in full. Stamp form (if stamp available).
4 Check the details on the applicantʼs original ID which must be one of the following:
 Supply two passport quality colour photos (45x35mm). One photo must be countersigned by the
verifier. Each photo must be a colour passport quality image of your head and shoulders
• passport • photo driving licence (see image above).The background must be white. Do not wear headwear or sunglasses.
• national identity card • card containing PASS hologram Your face must be completely visible. Do not smile, laugh or grimace.
• Home Office ID • UKBA Biometric Residence Permit
If you know the applicant personally the original ID can be one of the following:
• NHS Medical Card
• original or certified copy of a birth certificate
5 Write on the photocopy of the ID “I certify that I have seen the original of this

Too close
  
Top of head cut off Hair covering face Hat or cap worn

Smile or grimace Sunglasses

copy and that it matches the name and date of birth on this application form”  Photo 1 must be stuck or glued within the specified box marked ʻATTACH ONE PHOTO HEREʼ. PASS IS THE
adding your full name underneath, your signature and the date.  Photo 2 must be countersigned by the verifier. Do NOT stick or glue this photo to the form. UK GOVERNMENT’S
I certify that this
 Enclose the photocopy of your ID making sure the verifier has countersigned it first. APPROVED
Do NOT send the original ID. Photocopy ID must be sent in with this form.
I certify that I have seen the original of this
copy and that it matches the name and date
is a true likeness  Enclose postal order (payable to ʻCitizenCardʼ) unless you are paying by credit / debit card.
DO NOT SEND CASH OR CHEQUE.
STANDARD FOR
PROOF OF AGE
of Lily Steward
of birth printed on this application form.  Ifpaying
paying by credit/debit card make sure all sections have been completed and that the person
has signed next to the card number.

John Brown 28.05.14  Post the application by 1st class or 2nd class post, but if you want proof we have received it you
should use Recorded or Special Delivery.
FULL INSTRUCTIONS ON COMPLETING THIS FORM AT
28.05.14  Post to: CitizenCard, 36 Bromells Road, LONDON SW4 0BG
6 Write on the reverse of one photo “I certify that this is a true likeness of
[name]” and add your signature and the date. Check the photo matches the
The CitizenCard Scheme is operated
by CitizenCard Ltd a non profit
company limited by guarantee in
England & Wales Nº 366-99-49
www.citizencard.com
photo stuck or glued to this form. Registered Office:
7 CitizenCard will phone you at your workplace to verify the information supplied. 36 Bromells Road London SW4 0BG
Full Terms and Conditions at www.citizencard.com Data Reg. Nº Z7733342 (Data Protection Act 1998)

© CitizenCard Limited June 2014