Council Blue Badge Renewal Form – Fill Out and Use This PDF

Customer Services	BB1
Social Services

The Blue Badge Scheme of Parking

The Blue Badge Scheme of Parking

Concessions for Disabled and Blind People

Concessions for Disabled and Blind People

Apply for a new blue badge or renew your existing blue badge at:

Applicationwww.newportForm.gov.uk/bluebadge*(New/Renewal)

Application Form *(New/Renewal)

*Please delete which does not apply

*Please delete which does not apply

Swift No.	Expiry Date:
PART A	Please tick box as appropriate
Surname:		Mr/Mrs/Miss/Ms/
		Other:
Forenames:		Date of Birth:
Permanent Address:		Phone:
	Postcode:
Previous Address (if changed within last three years):		Mobile:
	Postcode:
Surname at Birth:		Town of Birth:
ETHNIC ORIGIN			Please tick box as appropriate ✓
Asian or Asian British - Asian other background
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Black other background
Black or Black British - Caribbean
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Other background
Other Ethnic Group - Any other ethnic group
Other Ethnic Group - Chinese
White - White British
White - White Irish
White - White other background
First Language:			Spoken Language:
Is English Spoken?			Interpreter Required?
Yes/No			Yes/No

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PART A (Continued)

Have you applied previously for a badge?

Yes/No

If Yes, give details

Current badge serial number:

Expires on:

PART B

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

Yes/No

2.Do you receive the higher rate of the mobility component of the Disability Living Allowance?

Yes/No

If yes, please supply evidence and date of award

from

to

3.Do you receive a Government Grant to your own vehicle? (e.g. motorbility grant)

Yes/No

4.Do you receive War Pensioners’ Mobility Supplement?

Yes/No

If you have answered YES to any of the above questions, there is no need to complete the remainder of the form.

Please sign the declaration below and return the form with written evidence and details of your relevant award

(e.g. letter of award Department of Work and Pensions).The supporting documents must be a good clear photocopy, if you cannot obtain a photocopy, please send the original letter with a self-addressed envelope and it will be returned. Or alternatively, you may bring them to the office with your application to be photocopied and verified.

DECLARATION

I declare that, to the best of my belief, all statements I have made on this form are true.

I have enclosed documentary evidence of my eligibility to be issued with a Disabled Person’s Parking Badge under one of the above criterion.

Signature:	Date:
NAME (PLEASE PRINT):

APPLICANTS QUALIFYING UNDER PART B INCLUDE 1 PASSPORT SIZE 2''X2'' COLOUR PHOTOGRAPH.

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PART C

1.Please describe your medical condition or disability and how long you have had the condition/s:

2.How does this affect your ability to walk?

Is this: Constant

Intermittent

3.Do you use a walking aid or wheelchair?

Who assessed you and when was this equipment provided for you?

4.How far are you able to walk, without help from another person, or having to stop because of discomfort or breathlessness? (This is an important question so please answer carefully. If you cannot estimate a distance in yards or metres, please try to use familiar landmarks in your locality)

5.When did you last see your GP, or Consultant about your mobility problems?

6.Have you ever applied for the Mobility Component of Disability Living Allowance?

Yes/No

If yes, please give dates of application(s) and outcomes:

7. Would you like to receive information on Disability Living Allowance?	Yes/No
Are you a car driver?	Yes/No
Have you registered your disability with the DVLA?	Yes/No

8. Is there any other information you wish to add to support your application?

9. Would you like any further information or advice on services which may assist you? (Please give details)

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PART 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:

PART E GP Details

Name of GP:

Address of GP

Postcode:

Are you willing to have a medical examination to determine the extent of your disability for the purpose of obtaining information to support your application?

Yes/No

DECLARATION

I declare that, to the best of my belief, all statements I have made on this form are true.

I have enclosed documentary evidence of my eligibility to be issued with a Disabled Person’s Parking Badge under one of the above criterion.

Signature:	Date:
NAME (PLEASE PRINT):

Applicants qualifying under Part C and D will be contacted later regarding a photograph.

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DATA PROTECTION ACT 1998

The information you provide may be processed by computer or retained on paper records and will be used for the administration of the Council’s Blue Badge Scheme of Parking Concessions for disabled and blind people.

The Council has a duty to protect public funds and may use this information you have provided to prevent and detect fraud. We may also share information, for the same purposes, within the Authority and other organisations that handle public funds. It will not be used for any other purposes.

PERMISSION TO CHECK
COUNCIL TAX REGISTER	YES	NO
FOR PROOF OF ADDRESS	Please tick appropriate box

PERMISSION TO CHECK
ELECTROL REGISTER	YES	NO
FOR PROOF OF IDENTITY	Please tick appropriate box

OFFICE USE ONLY
Automatic Criteria:
Documents received:	Yes/No Checked by:
Medical requested date:	Returned:

OUTCOME:
Badge Agreed	Automatic Renewal / Renewal / Reassessment / Review in ( ) yrs.
Badge Refused

Reason: .......................................................................................................................................................................................................................................

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

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

Signed: .......................................................................................................................................................................................................................................

Date: .....................................................................................................................................................................

Refusal letter sent date: .....................................................................................................................................

2012_06_020

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OFFICE ADMINISTRATOR USE ONLY

OFFICE ADMINISTRATOR USE ONLY

Date Application Received.................................................................................................................................................................................................

Letter to Applicant..................................................................................................................................................................................................................

Date Photo/Fee Received ..................................................................................................................................................................................................

PO/Cash/Cheque ....................................................................................................................................................................................................................

Receipt Number ......................................................................................................................................................................................................................

Date Badge Issued ..................................................................................................................................................................................................................

Date Badge Expires................................................................................................................................................................................................................

Badge Serial Number ............................................................................................................................................................................................................

Entered onto Computer .....................................................................................................................................................................................................

PLEASE RETURN TO:-

Newport City Council

Blue Badge Department, Information Station, PO Box 888, Queensway, Newport, NP20 9LX

For the Attention of the Blue Badge Administrator

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