Rejsekort Order Form Adult

(from 18 years)

R201E

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:
Adult

Rejsekort Flex (no photograph)

Card user:
Adult

No photo option

Young Person with DSB WildCard/Arriva Wundercard

Child (up to and including 15 years)

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

Pensioner

Dog

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

Card holder data

Bicycle

(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

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

New customer living abroad or without

CPR number. Form R225 enclosed

* 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

4.5 cm

3.5 cm

R201 1 (oktober 2013)

R201 1 (2. oktober 2013)

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

I wish to receive marketing
material from:

DSB

(You may check several boxes)

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

Rejsekort Order Form Adult

(from 18 years)

R201

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

Send the form to:

Did you forget something?

DSB
Kundecenter Rejsekort
Postboks 363
2630 Taastrup

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

R201 1 (2. oktober 2013)

Customer
no.:

Rejsekort
no.:

Rejsekort issued

Rejsekort to be issued and sent to customer

New customer (2 x ID)

Existing customer (verified by search in Rejsekort system)

Passp
ort

ID1 (preferably
with photo)

Driving
licence

Health
insurance card

Birth/baptism
certificate

Photo enclosed

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)

R201 1 (oktober 2013)

3 0 8 4 3 0

Health
insurance card

Date of issue:

Proof of address

(issued within the last 12 months)

Address and CPR no.

verified

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