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Social Welfare Services FT 27 Application form for Data Classification R Replacement Free Travel Pass Please use BLOCK LETTERS Please answer all questions and place an X in the relevant boxes. Please give details of why you are applying for a replacement pass in the space provided To be completed by garda Part 3 I certify that the person named in Part 1 has reported the loss/theft/destruction of their Department of Social Protection Free Travel Pass at this Garda station delete as appropriate. Please have Part 3 completed at a Garda Station* Your own details Part 1 1. Your PPS No* 2. Title insert an X or specify Mr. Other Ms. 3. Surname 4. First name s 5. Your date of birth D D M M Y Y Y Y Contact Details 6. Your address 7. Your telephone number MOBILE LANDLINE 8. Your email address Declaration I declare that all the information I have given on this form is accurate. I will tell the Department when my circumstances change. Date Signature not block letters Warning If you make a false statement or withhold information you may be prosecuted leading to a fine a prison term or both. Part 1 continued 9. Are you Single Cohabiting Married In a Civil Partnership Separated A surviving Civil Partner Divorced A former Civil Partner you were in a Civil Partnership that has since been dissolved Widowed 10. Have you changed address recently If Yes please give details of your previous address No Yes Details of last Free Travel Pass Part 2 11. Garda Station Official Stamp Garda ID Send this completed application form to Free Travel Section Department of Social Protection College Road Sligo LoCall 1890 500 000 from the Republic of Ireland only Note The rates charged for using 1890 LoCall numbers may vary among different service providers. Data Protection and Freedom of Information We the Department of Social Protection will treat all information and personal data you give as confidential* We will only disclose it to other people or bodies according to the law. Explanations and terms used in this form are intended as a guide only and are not a legal interpretation* 0K 05-11 Edition May 2011. Please have Part 3 completed at a Garda Station* Your own details Part 1 1. Your PPS No* 2. Title insert an X or specify Mr. Other Ms. 3. Surname 4. First name s 5. Your date of birth D D M M Y Y Y Y Contact Details 6. Your address 7. Other Ms. 3. Surname 4. First name s 5. Your date of birth D D M M Y Y Y Y Contact Details 6. Your address 7. Your telephone number MOBILE LANDLINE 8. Your email address Declaration I declare that all the information I have given on this form is accurate. Your telephone number MOBILE LANDLINE 8. Your email address Declaration I declare that all the information I have given on this form is accurate. I will tell the Department when my circumstances change. Date Signature not block letters Warning If you make a false statement or withhold information you may be prosecuted leading to a fine a prison term or both. I will tell the Department when my circumstances change. Date Signature not block letters Warning If you make a false statement or withhold information you may be prosecuted leading to a fine a prison term or both. Part 1 continued 9. Are you Single Cohabiting Married In a Civil Partnership Separated A surviving Civil Partner Divorced A former Civil Partner you were in a Civil Partnership that has since been dissolved Widowed 10.