Are you registered as blind under the National Assistance Act 1948?
Yes
No
If Yes, please give the name of the local authority with which you are registered
2.
Do you receive Mobility Allowance or the higher rate of the mobility component of the Diasability Living Allowance?
Yes
No
If Yes, please supply evidence ( e.g a copy of an official letter confirming an award of the allowance )
Please note: if you need to include such evidence you will need to print this form and post it to us rather than submitting it online.
3.
Was your vehicle supplied by the Department of Health and Social Security, the Scottish Home and Health Department or the Welsh Office?
Yes
No
If Yes, please give details:
4.
Do you receive a Government grant towards your own vehicle?
Yes
No
If Yes, please give details:
5.
Do you receive War Pensioners Mobility Supplement?
Yes
No
If Yes, please give details:
Important Notes - Please read before completing sections C or D
If you have answered No to all the questions in Section B you will qualify for a badge only if you cannot walk or can walk only with severe difficulty or if you hold a valid driving licence and have a severe disability in both upper limbs and are unable to turn by hand the steering wheel of a vehicle even if that wheel is fitted with a turning knob.
The intention of this scheme is that only very severely disabled people will qualify under
these conditions.
It is essential that each application made under Section C or D is considered carefully and so it will be necessary to seek information from the Medical Practitioner who is treating you for your disability for such applications. If you have not seen your Medical Practitioner for some time, it may be advisable to visit them to make them aware of the nature of your disability so that, when requested, they will be able to provide Social Care and Health with the information that is required in order for Social Care and Health to assess your eligibility.
Badges will only be issued to people who have a permanent and substantial disability which
causes inability to walk or very considerable difficulty in walking or to drivers who cannot turn by hand the steering wheel of a vehicle.
People with temporary disabilities, such as a broken leg, or intermittent disabilities will not qualify for a badge.
If you ticked No to all the questions in section B but still think you may qualify for a badge after reading these notes then please read Sections C and D.
Section C
Complete this part only if you consider that you have a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking.
1.
What is the nature of your disability and its effect on your mobility?
2.
What is the maximum distance you can walk without stopping, suffering from severe discomfort or requesting help from another person?
3.
Do you regularly use a walking aid?
Yes
No
If Yes, please state type of aid:
Section D
Complete this part only if you hold a valid driving licence and have a severe disability in both upper limbs and are unable to turn by hand the steering wheel of a vehicle even if that wheel is fitted with a turning knob.
1.
What is the nature of your disability?
2.
Do you drive a specially adapted car?
Yes
No
If Yes, please state type of adaptation:
Section E - To be completed if you have completed sections C or D
1.
What is the name and address of the Medical Practitioner who is treating you for your disability? Medical Practitioner's name:
Medical Practitioner's Address:
Medical Practioner's Postcode:
2.
Are you willing to have a medical examination with your Medical Practitioner if they require one to determine the extent of your disability for the purpose of obtaining information to support your application?
Yes
No
Section F - To be completed in all cases
Should your application be successful you will be required to supply 2 recent passport type photographs signed on the reverse by the applicant along with the appropriate administration fee. Please do not send photographs or fee until requested.
I declare that to the best of my belief all the statements I have made on this form are true and I agree to the local authority contacting my family doctor if necessary for the purpose of obtaining information to support my application.
