Rejsekort Order Form Adult (from 18 years) R201E

1

R201 1

(okto

ber

2013)

R201 1

(2. okto

ber

2013)

Rejsekort Order Form Personal/Flex for an adult person (from 18 years). If you are a new customer and you live abroad or do not

have a CPR number, you must also complete form R225. Contact Rejsekort Customer Services to request form R225.

Select Rejsekort and customer type (Check 1 box only)

Rejsekort Personal: Your name (as registered in CPR) will be printed on the front of your Rejsekort.

Customer type:

Rejsekort Flex (no photograph)

Card user:

Adult No photo option

Adult

Young Person with DSB WildCard/Arriva Wundercard Photograph obligatory. You must also have a valid DSB WildCard/Arriva Wundercard with you when you

travel. Child (up to and including 15 years)

Pensioner Photograph obligatory. Enclose a copy of ID card and pension notification if you are not yet 65 years old.

Dog Bicycle

Card holder data (machine-readable, one character per field) * Obligatory data. Use your name and address as registered in CPR. If you fail to do this, we are not permitted to issue you a Rejsekort.

New customer

New customer living abroad or without CPR number. Form R225 enclosed

I am already a Rejsekort customer and have previously submitted proof of identity.

* First name(s):

* Family name:

* Address:

* Postcode:

* Town:

* CPR number:

* Telephone no.:

If you want to have access to Online Self-service functions at rejsekort.dk, enter your e-mail address.

E-mail:

Payment Agreement (Check 1 box only) The right of cancellation in the Danish Consumer Protection Act does not apply when you buy a Rejsekort.

Rejsekort Personal is free of charge. Rejsekort Flex costs DKK 50.

I want to set up a payment agreement using my Dankort

If my Rejsekort account is created at a point of sale, I pay DKK 100 into the

account. I can use this sum to pay for travel. I agree to a payment agreement with Rejsekort A/S.

The agreement is managed by DSB I can travel with all the associated transport operators I am liable to notify Rejsekort Customer Services if I change my payment card or if

my payment card expires My Rejsekort is set to top up with DKK 300 when the balance on my account is less

than DKK 50. I can top up twice in 24 hours. To change these settings, see rejsekort.dk/selvbetjening

I may terminate the reload agreement at any time

No reload agreement You pay directly at a point of sale or you pay a bill, which we will send in the mail.

You pay DKK 100 which you can use to pay for travel If you receive your Rejsekort with a bill in the mail, you pay DKK 100 on the bill

It is possible that the bill arrives separately and after the Rejsekort I can top up my Rejsekort account at rejsekort.dk/selvbetjening any Rejsekortautomat or a point of sale I can subsequently create a reload agreement at rejsekort.dk/selvbetjening

Consent to marketing material (You may check several boxes)

I wish to receive marketing material from:

DSB Movia

NT

Metro

Sydtrafik

Arriva

Yes, please notify me of special offers, product news, campaigns and benefit schemes. The transport companies I have

selected above may contact me via e-mail and text message. Such information may concern Rejsekort A/S or the transport company's (or companies') own special offers, products, campaigns and benefit schemes. I hereby grant Rejsekort A/S permission to divulge my name, address, mobile phone number and e-mail address to the transport company/companies I have selected above for the sole purpose of their sending the above-stated information to me. You can unsubscribe from this service at any time. Any messages sent to you will include information as to how you can unsubscribe.

Don't forget to sign on the back

4.5

cm

3.5 cm

Rejsekort Order Form Adult (from 18 years) R201

1

R201 1

(okto

ber

2013)

R201 1

(2. okto

ber

2013)

When sending the form don't forget to enclose copies of ID and a photograph (if required)

Send the form to:

DSB

Kundecenter Rejsekort

Postboks 363

2630 Taastrup

Did you forget something?

1. New customers: Send copies of 2 different types of proof of identity. One of these should preferably have a photograph and at least one must include your address. Valid proof of identity: health insurance card, passport, residence permit, driving licence, baptism or birth certificate, pension notification or proof of address (issued within the last 12 months).

2. Existing customers: You do not have to submit copies of proof of identity if you have previously purchased a Rejsekort Flex or Rejsekort Personal.

3. Don't forget also to send a copy of your pension notification if you receive a pension and are not yet 65 years old. (Pension notification must have been issued within the last 12 months.)

4. Photograph if required (pensioner and young person) 5. Please read our travel regulations to make sure that you use your Rejsekort correctly and

make the most of what it has to offer. Read travel regulations at rejsekort.dk 6. Don't forget to sign the form

Don't forget to call if you have ordered a reload agreement. If you fail to call, you will not receive your Rejsekort.

You must call Rejsekort Customer Services to give us your payment card details

You will receive an e-mail when we are ready to receive your payment card details not earlier than 7 days from the day you submit/send the application form

If you have not given us your e-mail address, you must call us of your own accord. You must call us within two months. If not, your order will be cancelled

Call +45 70 11 33 33. Select "betalingsoplysninger" (payment options) in the telephone menu. Select DSB Always have your Visa/Dankort ready, when you call. Be prepared to give your CPR number and payment card

details during the call If you check the "No reload agreement" box, you are not required to call. You will receive a bill in the mail

Consent and signature

I hereby grant Rejsekort A/S and the associated transport companies permission to manage, collate, register, store

and exchange the following data 1) my personal details, including my CPR number, for the purpose of registering me as a customer and also (if necessary) to register me on the blacklist, cf. Section 6 of the terms and conditions of use of Rejsekort, and 2) details of transactions made on my Rejsekort account and journeys made with a view to settlement of the cost of travel. For a list of the associated transport companies, see rejsekort.dk. I declare that I have read and accept Rejsekort A/S' terms and conditions of use and personal data policy. I can withdraw my consent at any time, cf. Article 38 of the Danish Act on Processing of Personal Data. I am aware that, in the event that I choose to withdraw my consent, I will not be entitled to hold a Rejsekort Personal or Flex card and that these cards will therefore be frozen when consent is withdrawn.

Solemn declaration

I hereby solemnly declare that the information I have given about names and addresses is correct.

Date Signature

Staff only: To be completed by staff

Customer no.:

Rejsekort no.:

Rejsekort issued

Rejsekort to be issued and sent to customer

Photo enclosed

New customer (2 x ID)

Existing customer (verified by search in Rejsekort system)

ID1 (preferably with photo)

Passport

Driving licence

Health insurance card

Birth/baptism certificate

Proof of address (issued within the last 12 months)

Residence permit

Date of issue:

ID no.:

Expiry date (if any):

Issued by:

ID2 (incl. address)

Health

insurance card Proof of address (issued within the last 12 months)

Address and CPR no.

verified

Date of issue:

Municipality:

A copy of pension notification if the applicant receives a pension and is not yet 65 years old (issued within the last 12 months)

With my signature, I solemnly declare that I have seen valid proof of identity or that I have verified that the applicant is an existing customer.

Name of point of sale Date and signature of employee Initials

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