Online Application

Details in bold and marked with an asterisk (*) must be completed. For help and data protection information on any field simply click the Help Logo next to it. This will cause another window to open.

Core Details
Tell us who you are:
* Enter your title (e.g. Mr, Mrs, Miss, Ms, Dr)
* Enter your forename
* Enter your full surname
* Enter your name as you want it to appear on the front of the card. This will default to a concatenation of your forename and surname.
* Enter your date of birth in the format dd mm yyyy  /  /
Field used to determine whether a person's date of birth has been verified.  Set to 0 (false) by default.
* Select your gender
What is your ethnic group?
* How would you describe your ethnic group?
Address Search
Please enter your house number and postcode in the fields below and click the button to look up your address:

Enter the details of the flat / subdwelling address
* Enter the house number or name of your home address
* Enter your street address
Enter your locality
* Enter your postal town in capital letters
Enter your district
* Enter the postcode of your home address
The Local Authority running the card scheme
Unique Property Reference Number
Enter your contact details:
Enter your home phone number
Enter your work telephone number
Enter your mobile telephone number
Enter your email address
For security, please enter a known fact (password) and a clue to help you remember it
* You need to provide a short clue which would help you to recall the personal fact without making it easy for others to guess.
* Choose a password for accessing your data on the website
We would like to share information with other Council departments where they are introducing future CCBC Card applications and 3rd parties working in partnership with the Council to provide CCBC Card services. Please tick the box if you do not wish your personal information to be shared in this way:
Choose whether you will allow your details to be forwarded to 3rd parties
CCBC may wish to contact you from time to time with information about activities, events and special offers. If you would like to receive this information, please tick your contact preferences:
Join the CCBC mailing list?
Join the CCBC mailing list?
Join the CCBC mailing list?
Join the CCBC mailing list?
* The expiry date for the citizen's card if it is never used  /  /
 /  /
* Leisure Management System Membership Identification Number generated on completion of the application process.
* Membership number from the library management system generated on completion of the application process.
 /  /

By submitting this form the applicant agrees to be bound by the terms and conditions (opens in a new window) of the CCBC smartcard scheme.

Helpdesk: 01443 863072