BLUE BADGE SCHEME RENEWAL FORM
ELIGIBLE WITHOUT FURTHER ASSESSMENT
Telephone enquiries: 0300 500 80 80
Monday – Friday: 8am - 8pm
Saturday: 8am – 12 noon
Please complete all sections of the application form that apply to you. You must provide evidence to support your application when asked to do so, and you must send a recent passport photo and a £10 fee with your completed application.
Section 1 – Information about youIf you are completing the application form on behalf of the badge holder, then please give their details in the appropriate section and sign the form on their behalf.
Title: / Mr ☐ Mrs ☐ Miss☐ Ms ☐
First name:
Surname:
Date of birth: / DD ☐☐ MM ☐☐ YYYY ☐☐☐☐
Address:
Postcode: / ☐☐☐☐ ☐☐☐
National Insurance number:
Serial number of your current badge:
Expiry date of your current badge:
Previous address if you have moved in the last 3 years:
Postcode: / ☐☐☐☐ ☐☐☐
Preferred method of contact: / ☐ / Home tel:
Tick all that apply and give details / ☐ / Mobile:
☐ / Email:
Section 2 – Evidence of eligibility
Please complete the box below that applies to you:
☐ / I am registered as severely sight impaired (blind)
You do not need to send evidence of your registration. Please go straight to section 3
☐ / I am in receipt of Disability Living Allowance at the Higher Rate for Mobility
Please send a photocopy of the letter confirming your entitlement. This letter must be dated within the last 12 months. It should give a start date and an end date, unless the award is indefinite. If you need a replacement letter then contact the Pensions, Disability and Carers Service on 08457 123456
☐ / I am in receipt of the Mobility Component of the Personal Independence Payment
Please send a photocopy of all the pages of your letter of entitlement issued within the last 12 months
☐ / I am in receipt of the War Pensioners Mobility Supplement
You do not need to send further evidence of your award. Please go straight to section 3
☐ / I am in receipt of a benefit under the Armed Forces and Reserve Compensation Scheme
You do not need to send further evidence of your award. Please go straight to section 3.
Section 3 – Applies to ALL applicants
Please send:
☐Proof of your address, dated within the last 12 months
☐A passport photograph of you taken in the past 1 month (please print your name on the back)
☐A cheque or postal order for £10 made payable to Nottinghamshire County Council. Please do not send cash through the post.
If you do not send this information to us, your application will be delayed.
Proof of your address, dated within the last 12 months
We need to check that you are a resident in this local authority area before we can process your application. Please enclose a photocopy of one of the following, bearing the name and address of the person that the badge is for:
☐Council Tax bill dated within the last 12 months, bearing my name and address
☐ A bank statement dated within the last 12 months, bearing my name and address
☐ A copy of a valid driving licence
☐ Benefit letter from the DWP dated within the last 12 months
☐ Housing benefit (or other type of benefit) award letter dated within the last 12 months
☐ Pension letter from the Pension Service dated within the last 12 months
☐ If under 16, a confirmation letter from the school that the child attends that school
Please nominate the vehicle registration number(s) for the main cars in which you intend to use the Blue Badge (up to 3 registration numbers should be nominated, but please remember that other vehicles can be used):
Section 4 – Mandatory declarations
Please read the following declarations. In order for us to process your application you must agree to and tick all of these declarations. If you do not then we will be unable to process your application.
☐ / I confirm that, as far as I know, the details I have provided are complete and accurate. I realise that you may take action against me if I have provided false information in this application form
☐ / I confirm that the photograph I have submitted with my application is a true likeness of me
☐ / I confirm that I do not currently hold a Blue Badge issued by a different local authority
☐ / I understand that I must not hold more than one valid Blue Badge at any time
☐ / I understand that I must promptly inform my local issuing authority of any changes that may affect my entitlement to a badge
☐ / I understand that you will deal with all documents relating to this application in line with the data Protection Act 1998, and you may share them with other local authorities, the police and parking enforcement officers to detect and prevent fraud
☐ / I agree that I will not allow any other person to use the badge for their benefit and I agree that I will use the badge in accordance with the rules of the scheme as set out in the “Blue Badge Scheme: Rights and Responsibilities” booklet which will be sent to me with the badge.
Your signature against the declarations in Section 4 of the application form
Your signature:
Date of application: / DD ☐☐ MM ☐☐ YYYY ☐☐☐☐
If you are signing on behalf of the badge holder please print your name and your relationship to him/her:
Name: / Relationship:
Section 5 – Your consent to use your information to improve the service you receive
Please read and tick the following optional declarations if you consent to them:
☐I consent to the local authority checking any information already held by social care services on the basis that:
- It can help to determine my eligibility for a Blue Badge
- It may speed up the process of my application
- It may enable a decision to be made without the need for a mobility assessment.
☐I agree to the disclosure of the information included in this form to other local authority departments/service providers so that I can be informed about other services that may be of benefit to me.
Returning your form
Wherever you live in the county, please send your completed form back to:
The Blue Badge Team
Nottinghamshire County Council
Customer Service Centre
PO Box 9320
Nottingham, NG15 5BL
Telephone: 0300 500 80 80 for all queries about your application
Opening times: Mon-Fri 08:00 - 20:00 / Sat 08:00 -12:00
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