Section A – To be completed by all applicants
Title:
eg Mr, Mrs / Surname:
First name(s):
Date of birth:
Present address:
Postcode: / Telephone No:
Email address:

Please  as appropriate

Section B – Automatic entitlement
Are you registered as severely sight impaired (blind) under the National Assistance Act 1948? / Yes
Do you receive the Higher Rate Mobility component of the Disability Living Allowance? (Not Care Component or Attendance Allowance). / Yes
Do you receive War Pensioner Mobility Supplement? / Yes

If you have ticked yes to any question in Section B please proceed to Section D

Section C – Discretionary entitlement
1.Do you have a physical disability that means that you are unable to walk very far? / Yes
2.Do you drive a motor vehicle regularly, have a severe disability in both arms, and are unable to operate all or some types of parking meter? / Yes
3.Are you applying on behalf of a child less than 2 years of age who has a condition requiring transportation of bulky medical equipment, or who has a highly unstable condition which needs quick access to transport to hospital or home, or where there may be a need to stop to perform an urgent medical procedure? / Yes
Section D – Only complete to renew a Blue Badge
1.What is your existing Blue Badge number?
2.Was your Blue Badge issued by Essex County Council: / Yes No

Please  as appropriate

Data Protection Agreement – Statement:
The information you have provided (including any medical data) will be verified, securely retained and used by ECC only for the purposes of processing and corroborating blue badges and the prevention or detection of fraud. It may be necessary to share this information with other departments and organisations, which handle public funds, for the same purpose.
All information will be managed in accordance with the Freedom of Information Act 2000 and the Data Protection Act 1998. ECC is the data controller for the purposes of the Data Protection Act 1998. If you have any concerns about the way we handle personal information or would like to see any personal information held about you by Essex County Council please contact Information Sharing Information Security (ISIS): Essex County Council, PO Box 11, Chelmsford, CM1 1LX.,
Tel: 08457 430430, Email:

By signing this document you agree that the applicant is responsible for the use of the Badge. Failure to comply can result in a fine of up to £1000 and/or confiscation of the Badge.

I declare that all statements I have made on this form are true.

Section E – To be completed by all applicants
Name: / Date:

I am the applicant I am the applicant’s representative

Please sign in both boxes as one will be kept on file and the other used should you qualify for a badge

(ECC11098)

Page 1 of 2