SS4/5
Rev. 26/08/10
BLUE BADGE SCHEME OF PARKING CONCESSIONS FOR DISABLED
AND BLIND PEOPLE
When completed please return this form to:
Blue Badge Service
Newporte House
Low Moor Road
Lincoln
LN6 3JY
Telephone enquiries on 01522 550782
(Mon to Thur 9.00 a.m. to 5.00 p.m.
Fri – 9.00am – 4.30 pm)
(Mon to Fri 9.00 a.m. to 5.00 p.m.)
New/Renewal Application Form
Section A Personal details (If completing form on behalf of a child under 16 years of age,
please provide their details in appropriate sections and sign form on their behalf)
Mr/Mrs/Miss/Ms
(Delete as required)
Male/Female
Surname
Forenames
Address
Town
Date of Birth
Post Code
Daytime Contact Number
National Insurance number
(National Insurance numbers start with
two letters followed by six numbers, then
another letter)
e-mail Address
Previous address if different in the last three years
Address
Post code
Tel
RENEWALS ONLY
Current Badge Expiry Date
Current Badge Number
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SS4/5
Rev. 26/08/10
SECTION B
1. Registered Severely Sight Impaired (Blind)
Are you registered as severely sight impaired under the National Assistance Act 1948?
Yes
No
If yes, please provide a photocopy of the relevant documentation.
2. Higher Rate mobility component of Disability Living Allowance
(NOT Attendance Allowance)
Do you receive Disability Living Allowance at the Higher Rate for mobility?
Yes
No
If yes, please provide a photocopy of recent evidence (e.g. an official letter (available from
DWP Tel no: 08457 123456) confirming an award of the allowance and the expiry date if
applicable.
3. War Pensioners’ Mobility Supplement
Do you receive War Pensioners’ Mobility supplement?
Yes
No
If Yes, please supply a photocopy of the evidence (e.g. an official letter confirming award
of War Pensioners’ Mobility Supplement)
If you have answered YES to any question in section B please go to Section D
If you have answered NO to all questions in Section B, please go to Section C
Important notes For Section C – Please read before completing
If you have answered NO to all the questions in Section B, and applying as an individual,
you will only qualify for a badge if you or the person on whose behalf you are applying:
 Is over two years of age and has severe disability affecting both arms,
drives regularly and cannot use or finds it difficult to use parking meters;
 Is over two years of age and is unable to walk or has considerable
difficulty walking due to a permanent or substantial disability;
 Is a child under the age of two, who has a medical condition requiring
bulky medical equipment or immediate access to a vehicle for treatment.
Please read the attached notes for further guidance if you are unsure if this applies to you.
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Rev. 26/08/10
SECTION C
Eligible subject to further assessment
1. Severe disability in both arms.
1(a) Do you satisfy all of the following?

Drive regularly
Yes
No

Have a severe disability in both arms
Yes
No

Unable to operate or have considerable
difficulty operating all or some types of
parking meter.
Yes
No
Please describe your medical condition and the adaptations that you need to your
Vehicle.
.
.
1(b) Please explain the difficulties you have operating parking meters and pay
and Display machines
2. Unable to walk or experience considerable difficulty in walking due to a
permanent and substantial disability.
2(a) Do you have physical problems that restrict your walking?
Yes
No
If Yes please give details below:
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2(b) How far can you normally walk before you feel severe discomfort?
If you are not sure how far you can walk or how long it takes you, it may be useful to
measure this so you can give accurate information.
Yards/Meters
2(c) How long, on average, would it take you to walk this far?
Minutes
2(d) How many minutes can you walk for before you feel severe discomfort?
If you are not sure how long you can walk for, it may be useful to time this so you can
give us accurate information. By severe discomfort, we mean things like shortness
of breath, pain, extreme tiredness, or muscle spasms.
Minutes
2(e) Please tick the box that best describes your walking speed.
Normal or moderate
(about 51 mtrs/55yds or more than a
minute)
Slow
(about 40 to 50 mtrs/44 to 54 yds in a
minute)
Very Slow
(less than 40 mtrs/44 yds a minute)
2(f) Please tick the box that best describes the way you walk.
Normal
Adequate
For example, you walk with a slight limp.
Poor
For example, you walk with a heavy limp, a stiff leg
or shuffle, or have problems with balance.
Extremely Poor
For example, you drag your leg, stagger, use
swing through crutches or need physical support.
If there is not a box that describes the way you walk, tell us in your own words about
the way you walk .
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2(g) Please list the walking aid(s) you use and frequency of use;
2(h) Please give name and address of your GP
Name of G.P.
Name of Surgery
Surgery Address (Please state full address)
Telephone Number:
2(i) Apart from your GP, in the last 12 months, have you seen anyone in
connection with the illness/disability that affects your mobility?
(For example, a hospital doctor or consultant, district or specialist nurse,
occupational therapist, physiotherapist, audiologist.
Please tell us their professional address where you see them, such as health
centre or hospital)
Yes No
No
Their Name
Title
Name
(Mr, Mrs, Miss, Ms
Dr)
Their profession or
Specialist Area
The Address where
you see them
Which of your illnesses or disability do you see them for?
How often do you usually see them because of your illness or disability?
When did you last see them because of your illness or disability?
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3. Are you applying on behalf of a child under two years who either
3(a) Has a condition requiring transportation of bulky medical equipment at all
times?
Yes
No
What type of bulky equipment is required ?
and/or
3(b) Has 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 child’s medical condition
3(c) Name and Address of Child’s medical consultant
Name
Address
It would be useful if you could provide a supporting letter from your child’s
medical consultant e.g. Paediatrician, giving details of the child’s medical
condition and the type of medical equipment they need.
What is your relationship to the child?
e.g parent, guardian, aunt, grandparent
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SS4/5
Rev. 26/08/10
SECTION D
Driver/passenger status and vehicle registration (to be answered by
all individual applicants)
Will you be a driver or passenger in a car when using a Blue Badge?
Driver
Passenger
If you are a car driver you will need to send a photocopy of your current Driving
Licence
Vehicle registration number for principal car in which the badge will be used
(one number should be nominated, but other vehicles may be used and a badge
transferred when necessary)
If you change your car please notify the Blue Badge team of the new registration
number.
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Rev. 26/08/10
PLEASE DO NOT SEND ORIGINAL DOCUMENTS AS WE CANNOT
GUARANTEE SAFE RETURN. IF YOU HAVE DIFFICULTIES PROVIDING
A PHOTOCOPY, PLEASE CONTACT THE NUMBER ON THE FRONT OF
THE FORM.
Please enclose all the relevant Documents:
Confirmation of address in the name of the applicant:
Please supply a photocopy of one of the following as proof that you live in the county.
Utility Bill
Council Tax Bill
Official letter from a
Government Department
or Bank
Which ever one you provide, must contain a date within the last three months to
show that you live in the County.
Confirmation of Identity in the name of the applicant:
You must attach a photocopy of one of the following as proof of your identity.
Birth/Adoption Certificate
Medical Card
Valid Driving Licence 
Passport
 If you are a car driver you will need to send a photocopy of your current drivers
licence
Supporting documents
Evidence that you are registered as severely sight impaired (Blind),
Or in receipt of Higher Rate of the Mobility Component of Disability Living Allowance
Or War Pensioner’s Mobility supplement (if applicable)
Enclosed recent evidence in connection to application for children under
Two (if applicable)
Photographs
Two Passport type photographs of the applicant must
accompany all applications. You may send photographs
taken from self service booths or any suitable photograph
cut down to an appropriate size (45mm high x 35mm wide)
35mm
45mm
The applicant should print their name on the back of both
Photographs.
Photographs should be no more than twelve months old and
must not have previously been laminated.
I have attached two photographs with my full name printed on the back
Yes
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Rev. 26/08/10
Declaration (to be completed by all applicants) All boxes MUST be ticked.
I declare that , to the best of my knowledge, all the information I have provided is
correct.
I understand that I must promptly inform my local issuing authority of any
changes that may affect my entitlement to a badge.
I agree to the local authority contacting an accredited health professional if
necessary, for the purpose of obtaining information to support my application.
Data Protection Act 1998
I understand that the information supplied by me on this form will be maintained
by the local authority and will not be disclosed to any other party save those who
are responsible for the enforcement of parking restrictions, those responsible for
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 and other Government Departments
or agencies, to validate proof of entitlement.
I agree to the local authority sharing information in this form with other local
authorities responsible for the Blue Badge Scheme and with police officers
and parking enforcement agencies for the purpose of preventing and
detecting crime.
Name (please print)
Signature
Date
Your signature is needed on the badge before it is laminated. To enable us to do this
please sign your name inside BOTH boxes below.
Signature 1
Signature 2
Please tick this box if you obtained this form via the LCC Connects Website
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SS4/5
Rev. 26/08/10
Which of the following best describes your ethnic background?
A
White
British
Irish
Other White background (please specify)
B
Mixed
White and Black Caribbean
White and Black African
White and Asian
Other Mixed background (please specify)
C
Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian background (please specify)
D
Black or Black British
Caribbean
African
Other Black background (please specify)
E
Chinese or other ethnic group
Chinese
Other ethnic group (please specify)
Please note that this information will have no bearing on your eligibility for a Blue Badge
but will be used for monitoring purposes only, and will not be released in a way that would
identify an individual.
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