Te Hunga Whaikaha Total Mobility form

Please confirm you live in the Greater Wellington Region. *

I live in the Greater Wellington Region

Due to the impact of disability, are you unable to use public transport some or all of the time? *

Due to the impact of disability, I am unable to use public transport some or all of the time.

First name(s) *

Last name *

Preferred name (if different):

Date of birth (dd/mm/yyyy) *

Phone number *

Email address *

Would you like to provide details for an alternative contact person?

I would like to provide details for an alternative contact person.

Unit or apartment number

Number & street name *

Suburb

City/town *

Post code *

Please tick if your postal address is different than your home address.

Preferred contact method *

Phone call

Text

NZ Relay

During your Te Hunga Whaikaha Total Mobility assessment, your assessor will ask you a few questions. Will you need an interpreter for this?

I will need an interpreter.

Do you have any other questions about Te Hunga Whaikaha Total Mobility?

Please confirm *

I have read the Metlink Privacy Statement and understand my information will be managed in accordance with the Privacy Statement.*