BB/Form/1a
BLUE BADGE APPLICATION
Telephone enquiries: 0300 500 80 80
Monday to Friday: 8am-6pm
Please complete all relevant sections of the application form and supply the appropriate documents to confirm your address, identity and evidence of eligibility. You will also need to provide a recent passport photograph and a £10 fee – cheque or postal order made payable to Nottinghamshire County Council, cash is not accepted.Your application may be returned to you if the correct information is not supplied.The local authority may refuse to issue a badge if you do not provide adequate evidence that you meet the eligibility criteria.
Section 1 – Information about youIf you are completing the form on behalf of an applicant who is under 16 or who is unable to complete the form themselves, please provide their details in appropriate sections and sign the form on their behalf.
Application for: / ☐New Badge / ☐Reapplication for existing badge Expiry date: ………/..……/..……
Title: / Mr ☐ Mrs☐ Miss☐ Ms ☐
First name:
Surname: / Surname at birth:
Gender: / Male☐ Female☐
Date of birth: / DD ☐☐ MM ☐☐ YYYY ☐☐☐☐
Place of birth: / Town: / Country:
National Insurance / Child Registration number: / ☐☐☐☐☐☐☐☐☐
Address:
Postcode: / ☐☐☐☐ ☐☐☐
Home tel: / Mobile: / Email:
Previous address(if you have moved in the last 3 years):
Postcode: / ☐☐☐☐ ☐☐☐
Do you currently hold a Blue Badge, or have you held a Blue Badge before? Yes ☐ No ☐
If yes,
Which local authority issued you with the badge?
What is the serial number on the badge?
Section 2 – Please tick the section that applies to the applicant
A)People who are registered Severely Sight Impaired (Blind).Please note that if you are registered as partially sighted then you should tick no to this question.
Are you registered as Severely Sight Impaired (Blind)?
Yes No
If yes, please state which local authority you are registered with: ______
If yes, do you give consent for us to check the local authority’s register of blind people to see whether your disability is already known to the council?
Yes No
If you are registered Severely Sight Impaired (Blind) anddo not give us consent to check your local authority’s register please enclose a copy of your certificate of Visual Impairment (CVI) or a BD8 form, signed by a Consultant Ophthalmologist.
B) People who receive Disability Living Allowance at the Higher Rate for Mobility.
Do you receive the Disability Living Allowance at the Higher Rate for Mobility?
Yes No
If yes, please supply a copy of the letter confirming your entitlement to the Higher Rate Mobility Component of Disability Living Allowance. This letter should give an award start date and, if not indefinite, an award end date. It also must be dated within the last 12 months. If it is not, you will need to contact the Department for Work and Pensions for a full copy of this letter containing your full entitlement on 0345 712 3456 (If your date of birth is before 1948, you will need to contact 0345 605 6055). If you are in receipt of the Higher Rate Mobility Component of Disability Living Allowance and do not provide us withthe information requested, we will not be able to continue with your application.
C) People who meet a ‘Moving Around’ descriptor for the Mobility Component of the Personal Independence Payment (PIP).
Does your ‘Moving Around’ descriptor for the Mobility Component meet/match any of the following statements?
Yes No
If yes, please tick the one that applies to you:
I can stand and then move unaided more than 20 metres but no more than 50 metres (8 points)
I can stand and then move using an aid or appliance more than 20 metres but no more than 50 metres (10 points)
I can stand and then move more than 1 metre but no more than 20 metres (12 points)
I cannot stand or move more than 1 metre (12 points)
If you ticked a statement above (8, 10 or 12 points); have you been awarded this benefit for an ongoing period?
Yes No
If no, when is your award of this benefit due to end?
DD MM YYYY
If you have ticked one of the previous statements, (8, 10 or 12 points) for the “Moving Around” descriptor of the Mobility Component of PIP, you must include a photocopy of the full letter, in its entirety, to confirm your entitlement. This letter must give an award start and, if not indefinite, an award end date.It must include a full breakdown of the details to your entitlement to the ‘Moving Around’ descriptor for the Mobility Component of PIP and must be dated within the last 12 months.If it is not, you will need to contact the Department for Work and Pensions for a full copy of this letter containing your full entitlement on 0345 8503 322. If you are in receipt of PIP and score 8 points or more in the “Moving Around” descriptor of the Mobility Component and do not provide us withthe information requested, we will not be able to continue with your application.
D) People who receive the War Pensioner’s Mobility Supplement.
Do you receive the War Pensioner’s Mobility Supplement?
Yes No
If yes, please supply a photocopy of the letter from the Service Personnel and Veterans agency (SPVA). If you have lost this letter then the agency can be contacted via the free phone enquiry number: 0800 169 22 77.
E) People who receive a benefit under the Armed Forces and Reserve Forces Compensation Scheme.
Do you receive a benefit under the Armed Forces and Reserve Forces Compensation scheme within tariff level 1-8 (inclusive) and have been certified by the SPVA as having a permanent and substantial disability which causes inability to walk or very considerable difficulty walking?
Yes No
If yes, please supply a letter from the Service Personnel and Veterans Agency (SPVA) which confirms the level of your award and that you have been assessed as having a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking. If you have lost this letter then the agency can be contacted via the free phone enquiry number: 0800 169 22 77.
If you have answered YES to any of the questions in section 2, now go straight to sections 5 and 6 of this application form. If you have answered NO to all the questions in section 2 please complete sections 3, 4, 5 and 6.
Section 3 – Please describe the difficulties you have with walkingPlease note that you will only qualify for a blue badge if you, or the person on whose behalf you are applying, are over two years of age and have a permanent and substantial disability which means you are unable to walk or have very considerable difficulty in walking.
Q1.Please describe all your medical conditions or disabilities and say how they affect your ability to walk: please include the medical terms if you know them:
Q2.Your general walking ability: Please answer yes or no to each of the following statements. / For office use only
I am unable to walk at all and use a wheelchair all the time / Yes / No
I am able to walk, but use a wheelchair for trips outside the home / Yes / No
I am able to walk, but struggle with longer distances or hills / Yes / No
I am able to walk around my home, but I am unable to climb stairs / Yes / No
I am able to walk around the supermarket to do my own shopping / Yes / No
I am able to walk and can use public transport for some of my local trips / Yes / No
I am able to walk well, including recreational walks / Yes / No
Q3. Please tick the box which best describes the way you walk:Please tick one box only. / For office use only
Normal - no specific problems with walking
Adequate – e.g. you walk with a slight limp
Poor – e.g. you walk with a heavy limp, a shuffle, or have problems with balance
Extremely poor – e.g. you drag your leg, stagger, swing through 2 crutches or need physical support
I am unable to walk at all
Other (please give details):
Q4. Are you able to walk outside without help from another person? Yes No / For office use only
If no, please tell us why:
Q5. Do you use any of the following?Yes No / For office use only
If yes, please tick whichever options apply to you
1 Walking Stick / 2 Walking Sticks
1 Elbow Crutch / 2 Elbow Crutches
Walking Frame / Rollator
Wheelchair
If you use a walking aid, please identify how you obtained them:
Purchased by me / Prescribed by an occupational therapist or physiotherapist
Other (please describe below):
Q6.Do you anticipate your conditions/disabilities will improve in the next 3 years? / Yes / No
If yes, please say why:
I am awaiting surgery in relation to the conditions which affect my walking / Yes / No
(please give the date of your surgery, if known)
I am awaiting treatment for the conditions which affect my walking / Yes / No
(please give the date of your treatment if known)
I am recuperating from surgery in relation to the conditions that affect my walking / Yes / No
(please give the date of your surgery)
Please give details of the healthcare professionals, or specialists (including your GP) who have been treating you in relation to the conditions which affect your walking:
Name / Job title / Hospital / Health Centre / Telephone Number
Walking Ability - Breathlessness
Q7. Please answer yes or no to each of the following statements: / For office use only
I am able to walk, but I get breathless if I walk for more than a few minutes / Yes / No
I am troubled by shortness of breath when hurrying on level ground or walking up a slight hill / Yes / No
I get short of breath walking with other people of my own age on level ground / Yes / No
I have to stop for breath when walking at my own pace on level ground / Yes / No
I get too breathless to leave my home, or after dressing / Yes / No
Ihave been prescribed oxygen so that I can carry out daily activities / Yes / No
Ifyes to any of the above, what are the medical conditions that cause your breathlessness?
Walking Ability - Pain
Q8.Do you find it painful to walk for more than a few minutes? Yes No / For office use only
If yes, is the pain:
Constant / When walking / After walking/at rest
How much pain do you experience when not walking?
(0=no pain, 10 = the worst pain imaginable)
0 1 2 3 4 5 6 7 8 9 10
How much pain do you experience when you are walking?
(0=no pain, 10 = the worst pain imaginable)
0 1 2 3 4 5 6 7 8 9 10
Are you currently taking any medication for pain relief? Yes No / For office use only
If yes, please identify below.
Medication / Dosage / Frequency
Q9. Are you seeking specialist treatment or attending clinics for pain relief? Yes No / For office use only
If yes, please identify below.
Surgeries / courses of treatment / specialist clinics: / Dates you received this treatment
Walking ability – distance, speed & time
Q10. Please identify Where are you able to walk comfortably to from home? (Please give the name of a road or a place)
How Long does this journey take you?
How far you are able to walk before you feel severe discomfort and have to stop, and how long it takes you to walk this distance. Please state the distance in either metres or yards. Please see the guidance notes at the end of this form if you need help with identifying distances.
I am able to walk:
Metres/yards before I have to stop and it takes me
Minutes to walk this distance.
Q11. Are you able to continue walking after a short rest? Yes No / For office use only
If yes, roughly how long are you able to walk for in total?
minutes
Section 3 - Consent to a mobility assessment
You may be asked to have a mobility assessment with one of our assessors. Please tick the following statement to say that you agree to this. If you are asked to have a mobility assessment and you either do not agree, or do not attend, we will not be able to continue with your application.
I understand that I may be required to undertake a mobility assessment with a healthcare professional that is independent of my existing care and treatment, in order to determine my eligibility for a Blue Badge.
If you are asked to have a mobility assessment, it will be at one of the following places. Please tick all the places that you are able to travel to:
Arnold – Civic Centre, Arnot Hill Park, Nottingham NG5 6LU
Retford – Bassetlaw District Council, 17B, The Square, Retford, Nottinghamshire DN22 6DB
Worksop – The Library, Memorial Ave, Worksop, Nottinghamshire S80 2BP
Beeston – Middle Street Resource Centre, 74 Middle Street, Beeston, Nottingham, NG9 2AR
Newark – Bridge Sure Start Children’s Centre, Lincoln Rd, Newark, Nottinghamshire NG24 2DQ
Mansfield – CISWO Berry Hill Ln, Mansfield NG18 4JR
Please tick this box if you get, or have had, social care support from the Council, for example, aids and adaptations to your house. If you get social care support from the Council, we will check our social care records to help to decide about your eligibility for a badge. This may avoid the need for a mobility assessment.
Section 4 – Further information in support of your application
Please identify any other medications you are taking in relation to your medical conditions.
Please continue on a separate sheet or enclose an old prescription if necessary.
Medication / Dosage / Frequency
Please add anything else that you think is relevant in support of your application for a Blue Badge.
Section 5 - Mandatory declarations
Please read the following declarations. They underpin the terms of applying for a blue badge.In order for us to process your application you must agree to all the declarations.
I confirm that, the details I have provided are complete and accurate.
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 I must use the badge in accordance with the rules of the scheme as set out in the ‘Blue Badge scheme rights and responsibilities’ leaflet which will be sent with the 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 understand that the local authority may contact an accredited healthcare professional if they need further information in support of the application
Section 6–Optional declaration
You may wish to tick this optional declaration to improve the service you receive from us. In doing so, you will be providing specific consent to the Council to allow us to share information about you with relevant departments and service providers within the authority.
I agree to the disclosure of the information included in this form to other council departments/ service providers so that I can be informed about other council services that may be of benefit to me.
Please send correspondence relating to my application in large text (this declaration is related to correspondence sent by the Blue Badge Team only).
Supporting documents (Identification) – We need to verify your identity and address in order to process your application. We can automatically do this via ‘Call credit’ using your name, address and date of birth (if the applicant is over the age of 18) If you choose this option you will not be required to post/email in proof of address or identity.
Information regarding ‘Call Credit’ can be found on the below website;
Nottinghamshire County Council Privacy statement;
Alternatively please see list of required documents below
I give permission for you to verify my identity and address with Call creditYour signature against the declarations and information supplied within this application form - all applicants must sign and date the form prior to submitting it. We may refuse to issue a badge if we have reason to believe that the applicant is not who they claim to be or that the badge would be used by someone other than the person to whom it has been issued.
Your signature:
Date of application: / DD MM YYYY
If you are signing on behalf of someone else please give your name and your relationship to the applicant:
Name: / Relationship
The application form asks you to describe the nature of your disability and to give an estimate of the maximum distance you can walk without assistance or severe discomfort. It can be difficult to accurately work out the distance you can walk. There are several things that can help you:
- Ask someone to walk with you and pace the distance you walk.
- The average adult step is just under one metre.
- The average double-decker bus is about 11 metres long.
- A full-size football pitch is about 100 metres long.
If you still find it difficult to work out the distance you can walk in metres, please tell us:
- The number of steps you can take, and how long, in minutes, it would take you to walk this distance.
- About your walking speed.
- The way that you walk, for example, shuffling or small steps etc.
Proof of address
We need to check that the applicant lives in Nottinghamshire 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:
Current Council Tax billbearing my name and address, dated within the last 12 months
A copy of a valid driving licence
Benefit letter from the DWP 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 the child attends
Housing benefit (or other benefit) letter dated within the last we months
Award letter from the Service Personnel and Veterans agency dated within the last 12 months
A confirmation letter from Social Services or other Local Authority service confirming the customer is resident at that address.
Proof of identity
We need to check the applicant’s identity to stop fraudulent applications for a badge. Please enclose a photocopy of one of the following as proof of the applicant’s identity:
Passport
Valid driving licence
Birth/Adoption Certificate
Marriage/Divorce Certificate
Valid Driving Licence
NCC Bus Pass
Certificate of British Nationality
Civil Partnership dissolution certificate
HMS Forces Card
Identity Card for foreign nationals
Section 7 – Returning this form
Please return the completed form to:
The Blue Badge Team Nottinghamshire County Council Customer Service Centre
PO Box 9320
Nottingham
NG15 5BL
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