BLUE BADGE APPLICATION FORM by fdjerue7eeu

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BLUE BADGE APPLICATION FORM

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									P.S.6151




                        ADULT SOCIAL SERVICES DIRECTORATE
           THE BLUE BADGE SCHEME OF PARKING CONCESSIONS
                   FOR DISABLED AND BLIND PEOPLE

                                   APPLICATION FORM

PART A - Individual Application Details                                     Please tick
(Applicants for an organisational badge should go to Part E)

             New application                           To replace lost/stolen badge


             Renewal application                       To replace faded badge
                                                       (please attach faded badge)
For renewal, please provide the following:

Badge No:                                       Expiry Date:

To replace lost/stolen badge please supply the following Noʼs (obtained from any
 police station).

Lost Property No:                                Crime Report No:


Will you be a driver or passenger in a car when using a blue badge?

Driver                              Passenger                            Both

Vehicle Registration Number of principal vehicle in which badge will be used:




(One number should be nominated but other vehicles may be used and the badge transferred
when necessary).

    BMBC is required under the Audit Commission Act 1998 to participate in the National Fraud
     Initiative (NFI) data matching exercise. In order to protect public funds we advise that the
information you have provided on this form may be used for the prevention and detection of fraud.
       Further details can be obtained on the Councilʼs website at http://www.barnsley.gov.uk



                      Please ensure you sign in the white box below.
                    The badge cannot be issued if this box is not signed.




                         Please return this application form to:
              BMBC Blue Badge Applications, PO Box 630, Barnsley, S70 9GB.                          1
    PHOTOGRAPHS
    Please enclose two recent passport-style photographs.
    Please ensure that you print and sign your name on the back of each photograph.

    FEE
    Please enclose a cheque/postal order for £2.
    Cheques should be made payable to Barnsley Metropolitan Borough Council.
    Cash should not be sent through the post.

     For Office Use Only To Be Completed by Barnsley Connects / Business Support Staff

     Application received by                                                                        Date


     Receipt Number


                                                        Evidence Presented                                        Evidence Verified




     Decision                               Approved                                          Refused


     Badge Number


     Authorising Officer


     Date Issued


     Action Taken: ...............................................................................................................................

     .....................................................................................................................................................

     .....................................................................................................................................................

     .....................................................................................................................................................

     .....................................................................................................................................................




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BLUE BADGE SCHEME - APPLICATION FORM

Please tick box           as appropriate.
Please complete in block capitals.

PART B - To be completed by ALL applicants
(Applicants for an organisational badge should go to Section E)

PERSONAL DETAILS
Surname                                                     Title (Mr, Mrs, Miss, Ms)



Forename(s)                                                 Date of Birth (DD/MM/YEAR)



Address



                                                            Postcode

Tel. No.                                                    E-mail

Previous Address (if moved within last three years)



                                                            Postcode

Tel. No.                                                    E-mail


CONFIRMATION OF ADDRESS

Please supply ONE copy of any of the following as proof that you live in the borough.

Utility Bill                                 Rent Book

Council Tax Bill                             Benefit Entitlement

Whichever one you provide, it must be dated within the last three months to show that you are
living in the county/borough.

CONFIRMATION OF IDENTITY

You must attach a photocopy of TWO of the following as proof of your identity.

Birth certificate/adoption certificate                Medical Card

Pink/new style driving licence                        Passport

Failure to do so may result in a delay in processing your application.

Further information in relation to Confirmation of Address and Identity can be found on page 10
                                                                                                  3
     PART C - Automatic Eligibility Without Further Assessment
              - To be completed by all applicants
    If you can answer YES to any of the questions below you are automatically entitled to a Blue Badge,
    as long as you can supply the evidence requested.

     ELIGIBILITY CRITERIA

     1.   Registered Blind
          Are you registered as blind under the National Assistance Act 1948?


                          Yes                           No

           If YES, please specify the local authority with which you are registered.




           EVIDENCE REQUIRED: Proof of registration (Form CV1 - Certificate of Visual
                                                                Impairment)



     2.    Higher Rate Mobility Component of Disability Living Allowance
           Do you receive Disability Living Allowance at the Higher Rate for Mobility?

                          Yes                           No

           If YES, please provide the following evidence:

           ­ An official letter from the Department for Work and Pensions confirming an
             award of the allowance dated within the last 12 months.



           If you have answered yes but do not have the required evidence please call the
           Department for Work and Pensions on 0845 7123 456 and request an up to date
           letter of entitlement of DLA to be sent out to you in the post.



     3.    War Pensionerʼs Mobility Supplement
           Do you receive War Pensionersʼ Mobility Supplement?


                          Yes                           No

           If YES, please provide evidence (e.g. an official letter from the Veterans Agency
           confirming a current award of War Pensionersʼ Mobility Supplement).




                  If you answered YES to any question in Part C, please go to Part F
                If you answered NO to all the questions in Part C, please go to Part D




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PART D - Assessed Eligibility

Important Notes for Part D - Please read before completing

If you have answered NO to all questions in Part C and are applying as an individual, you will
only qualify for a badge if you or the person on whose behalf you are applying:

       ­ Has a severe disability affecting both arms;

       ­ Is a child under the age of two suffering a medical condition requiring
         bulky medical equipment or immediate access to a vehicle for treatment;

       ­ Is unable to walk or has considerable difficulty walking due to a permanent
         and substantial disability.

PLEASE NOTE:

       ­ You must be physically incapable of visiting shops, public buildings and
         other places unless allowed to park close to your destination.

       ­ The entitlement depends on your ability to walk and considerations such as
         difficulty in carrying parcels will not be taken into account.

       ­ If you have a temporary disability, such as broken leg or waiting for
         corrective surgery, you will not normally qualify for a Blue Badge.

       ­ If you are under the age of 65, it is normally expected that you are in receipt of the
         Higher Rate Mobility Component of the Disability Living Allowance before applying
         for a car badge.


1.   Do you satisfy ALL of the following?

       ­ Drive regularly;

       ­ Have a severe disability in both arms; and

       ­ Unable to operate or have considerable difficulty operating all or some types
         of parking meter.

                     Yes                           No


Please describe your medical condition:




How does this affect your parking?




                                                                                                  5
    2.   Are you unable to walk or experience considerable difficulty in walking due to a
         permanent and substantial disability?

                           Yes                             No

    Please describe your medical condition:




    Give an idea of the maximum distance you can walk without, stopping, severe discomfort, or
    help from another person: (give distance in metres)




    3.   Are you applying on behalf of a child aged under 2 years?

                           Yes                             No


          (i) Does the child suffer from a condition requiring transportation of bulky medical
              equipment at all times?

                           Yes                             No

             and / or

          (ii) Does the child suffer from a condition that requires that they must be kept near a
               motor vehicle at all times in order to be treated for that condition in the vehicle, or
               to allow the child to be taken immediately to a place where they can be treated?

                           Yes                             No

    Please describe the childʼs medical condition:




    Does this require regular transportation of heavy equipment?

                           Yes                             No




    If YES, what type of equipment?




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PART D - Continued

MEDICAL EVIDENCE

It is essential that we carefully consider each applicant under Part D, so we ask your permission to
seek medical evidence of your disability. We have no obligation to take account of any non-requested
medical information, which you may wish to accompany this application.

 Please provide the following information about your doctor, a nurse, a consultant, a
 physiotherapist, or an occupational therapist.

 (You must have seen them within the last 6 months).

 Their Name


 Their Address




 Their Tel. Number



 What is their job?



 When did you last see them?



Do you possess a Form DS 1500 issued by your doctor or a health professional?

                        Yes

 If YES, please provide a copy.




                                                                                                       7
     PART E - Organisational Application

     If your organisation transports disabled people please complete this section


     Name of Organisation


     Main Contact - Name

     Address

     Postcode

     Tel

     E-mail


     Number of people in organisation

     Number of qualifying people for which the organisation
     is responsible

     Charity Number (if applicable)


     Describe why you are applying for a badge including how often it will be used and why




     Renewals Only

     Badge Number                           Expiry Date of Current Badge



    When making an application the organisation needs to make a declaration on the organisationʼs
    letter-headed paper. The declaration needs to say that they are an organisation concerned with
    the care of disabled people and that they will be using the vehicle solely for the purpose of
    transporting those people. Please include a list of clients, stating their disability.




                 PLEASE ENCLOSE A CHEQUE / POSTAL ORDER FOR £2.00

                                Cheques should be made payable to
                               Barnsley Metropolitan Borough Council



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PART F

DECLARATION (TO BE COMPLETED BY ALL APPLICANTS)

I declare that, to the best of my knowledge, all the information I have provided is correct.

I agree to the Local Authority contacting an accredited health professional if necessary
for the purpose of obtaining information to support my application.

I agree to return my Blue Badge when it is out of date or no longer needed.

Signed                                                                      Date


DATA PROTECTION ACT 1998

I understand that the information supplied by me on this form will be maintained by their Council
and will not be disclosed to any other party except for those who are responsible for the enforcement
of parking restrictions, to Transport for London in relation to discounts for congestion charging,
or otherwise as the law allows.

I further understand that the medical information I have supplied to support this application is
deemed to be “sensitive personal data” and I consent to its disclosure only to a third party who
is responsible for the operation and administration of the Blue Badge Scheme.


Signed



Date
(DD/MM/YEAR)


Name




CONSENT

If this application is being completed by a third party, then all applicants over the age of 16 years
must sign below to indicate that they give their consent to the named person acting on their
behalf. By signing below, the applicant also agrees, where necessary, for Barnsley Adult Social
Services to discuss their Blue Badge Application with the named third party.


Name of Third Party: ...................................................................................................................


Applicantʼs Signature:..................................................................................................................


Dated: ...........................................................




                                                                                                                                           9
     CONFIRMATION OF ADDRESS (1 x Proof of Address)


     Utility Bill                            Bank/Building Society Statement

     Rent Book                               Addressed Payslip

     TV Licence                              Valid Insurance Certificate

     Council Tax Bill/Statement              Mortgage Statement

     Benefits/Pension Official Letter        Credit Card Statement

     Vehicle Registration Document



     CONFIRMATION OF IDENTITY (2 x Proof of Identity)


     Existing Blue Badge with                Marriage/Civil Partnership
     photograph and signature                Certificate

     Birth/Adoption Certificate              Medical Card

     Passport                                Bus Pass

     NHS Card

     Driving Licence

     Shotgun Certificate




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PART G - Equal Opportunities Monitoring
We are committed to delivering services in a fair and non-discriminatory way, so that no one is treated
unfairly because of their sex, race or disability. To help us monitor this, please tick the details that
apply to you.



 Are you: Female                                       Male

 Age:           Under 16                               16 - 19                             20 - 24

                25 - 29                                30 - 34                             35 - 39

                40 - 44                                45 - 49                             50 - 54

                55 - 59                                60 - 64                             65+ above


 How do you describe your ethnic origin?                           Tick the appropriate box to indicate your cultural background


 Asian or British Asian

             Bangladeshi                     Indian                         Pakistani                        Asian Other*


 Black or British Black

             African                         Caribbean                      Black Other*


 Chinese or Other Ethnic Minority Group

             Chinese                         Any Other Background*


 White

             English                 Irish                Scottish                 Welsh                   White Other*


 Mixed

             White &                           White &                        White &                        Mixed Other*
             Black Caribbean                   Black African                  Asian


 *If “other” ticked above please indicate here ................................................................................

             Prefer not to say




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