Non-South Australian Transport Subsidy Scheme registration form

1. Given name
2. Surname
3. Date of birth

   Format the date as DD/MM/YYYY.
   For example, 01/12/1986 or 22/06/1993.
4. Street address
5. Suburb
6. Postcode

   A valid 4-digit postcode.
7. Email

   Provide your email address to receive real-time travel information via your personal journey summary.
8. Personal phone number

   Prefix numbers with a zero and do not include parenthesis. You may include spaces between numbers.
   For example, 0491570006, 0491 570 006, 0855507689 or 08 5550 7689.
9. Phone number for carer or personal contact

   This field is optional.
   If you would like a carer or personal contact to receive your real-time travel information, provide their mobile number.
   Prefix numbers with a zero and do not include the parenthesis. You may include spaces between numbers.

10. Do you use a wheelchair, scooter or large (ride on) mobility aide?

    • Yes
    • No
11. How long have you used the device for?

    This field is required only if you answered 'Yes' to question 10.
    For example, 9 months.
12. For what reason do you use the device?

    This field is required only if you answered 'Yes' to question 10.

Before completing this section, you will need to speak with an authorised witness. View the list of authorised witnesses.

13. Witness declaration

    I certify that l have spoken with an authorised witness and they:

    • have confirmed that I need to use a wheelchair, scooter or large (ride on) mobility aide; and
    • consent to being contacted by the Department for Infrastructure and Transport about my application.

    • Yes, I certify.
14. Witness name
15. Witness profession
16. Witness business address
17. Witness business phone number

    Prefix numbers with a zero and do not include parenthesis. You may include spaces between numbers.
    For example, 0491570006, 0491 570 006, 0855507689 or 08 5550 7689.