LONDON BOROUGH OF MERTON
ENVIRONMENT & REGENERATION DEPARTMENT
THE BLUE BADGE SCHEME OF PARKING CONCESSIONS FOR
DISABLED AND BLIND PEOPLE
IF YOU ARE AN EXISTING BLUE BADGE HOLDER PLEASE ENTER:
CURRENT BADGE NUMBER
EXPIRY DATE
PLEASE PROVIDE A PHOTOCOPY OF THE CURRENT BADGE IF NOT ISSUED BY LONDON BOROUGH OF MERTON
SECTION A
Full name of Applicant:
SURNAME:
MR / MRS / MISS / MS
FORENAME(S):
Full Address of Applicant:
Postcode:
Email (if applicable):
Telephone number:
Ethnicity:
Date of Birth:
Please tick
White British
Black British
Indian
White Irish
Black African
Bangladeshi
White Other
Black Caribbean
Pakistani
White and Black African
Black British African
Tamil
White and Black Caribbean
Black British Caribbean
Other Asian or Asian British
White and Asian
Black Other
Any Other Mixed
Chinese
Any Other
PROOF OF RESIDENCE: If you are not on the Electoral Roll of the London Borough of
Merton (i.e. registered to vote at elections) at the address given above, you MUST supply
evidence that you live there. Please tick boxes corresponding to the documentary proof
you are supplying (only ONE of the documents below are required):
Tenancy
agreement
Utility
Bill
Driving
Licence
Bank
Statement
TV
Licence
PHOTOGRAPHS - IMPORTANT NOTE:
Applications MUST be accompanied by two (2) preferably passport-style photographs of
the applicant which should be securely attached to the FRONT of the form. Both
photographs should be signed on the back by the applicant. Your photographs will be
returned if your application is unsuccessful after the appeal process if applicable. You may
send photographs taken from self-service booths or any suitable photographs cut down to
an appropriate size.
ANY APPLICATION RECEIVED WITHOUT PHOTOGRAPHS WILL NOT BE
CONSIDERED AND WILL BE RETURNED TO THE APPLICANT
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SECTION B
11..
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:
22..
Do you receive the
HIGHER RATE MOBILITY COMPONENT OF
DISABILITY LIVING ALLOWANCE ?
NO OTHER STATE BENEFIT IS RELEVANT TO THIS
QUESTION
N.B.
Yes

No

If Yes, you MUST supply evidence, i.e. a COPY of an official recently dated letter (i.e.
within the last year) confirming an award of the allowance or the Vehicle Excise Duty
Exemption Certificate.
If you do not have a recently dated letter you MUST obtain one from the
Department for Work and Pensions – please call 08457 123456 for a copy.
IF YOU DO NOT SEND PROOF OF ENTITLEMENT AS STATED ABOVE YOUR
APPLICATION WILL BE RETURNED TO YOU.
Please enter the expiry date of your eligibility as stated on the evidence you are
providing (your Blue Badge will expire on the same date if it falls within the next THREE
years). If the award is indefinite please enter “indefinite” in the box (your Blue Badge will
run for THREE years).
33..
Do you receive WAR PENSIONER’S MOBILITY SUPPLEMENT?
Yes

No

If Yes, please supply evidence (e.g. a COPY of an official letter confirming an award of
War Pensioners’ Mobility Supplement).
If you have answered Yes to any of the questions in SECTION B, please go to
SECTION D.
If you have answered No to all the questions in SECTION B, you may qualify for a
badge under SECTION C .
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SECTION C
IMPORTANT NOTES – PLEASE READ BEFORE COMPLETION
If you have answered No to all questions in SECTION B, you will qualify for a badge
only if you, or the person on whose behalf you are applying:
 Is unable to walk or has considerable difficulty in walking due to a permanent and
substantial disability
OR
 Has a congenital disability affecting BOTH arms OR
 Is a child under the age of two suffering a medical condition requiring bulky medical
equipment or immediate access to a vehicle for treatment.
The intention of the scheme is that only very severely disabled people will qualify under
these conditions.
Each application under SECTION C will be considered carefully. Further information
may be sought from your doctor who may ask you to have a medical examination.
Badges will only be issued to people who would otherwise find it impossible to visit
shops, public buildings or other places, or to drivers who cannot turn by hand the
steering wheel of a vehicle.
People with temporary disabilities, such as a broken leg or post-operative
mobility problems, will not qualify for a Badge.
11..
What is the nature of your disability?
22..
What is the maximum distance you can walk without stopping, experiencing severe
discomfort, or needing help from another person?
3.
If you are applying on behalf of a child aged under 2 years:
Does he/she suffer from a condition requiring at all times :
the transportation of bulky medical equipment OR
the child to be kept near a motor vehicle in order to be treated for that condition in the
vehicle OR
the child to be kept near a motor vehicle to allow them to be taken to a place where
they can be treated
Yes

No

If Yes, please describe the medical condition and, if applicable, the type of equipment
required:
SECTION D
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SECTION D
ALL APPLICANTS MUST COMPLETE THIS PART
11..
What is the name and address of your family doctor (General Practitioner)?
Name:
Address:
Postcode:
22..
Telephone number:
Are you willing to have a medical examination to determine the extent of your disability
for the purpose of obtaining information in support of your application?

Yes
No

DECLARATION
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.
Signed:
Date:
Please also sign the box below – DO NOT EXCEED THE BOUNDARIES OF THE BOX
This signature will be transferred to the badge if your application is successful.
IF THIS BOX IS NOT SIGNED YOUR APPLICATION MAY BE REJECTED
Your personal information will be held and used in accordance with the requirements of the
Data Protection Act 1998. We have a duty to protect the public funds we administer and
may use the information you provide for the prevention and detection of fraud. We may
also share this information with other bodies responsible for auditing or administering public
funds for these purposes. For further information, go to http://www.merton.gov.uk/legal/nfifdp.htm or contact the Data Protection Officer, by email: data.protection@merton.gov.uk or
by
‘phone
020
8545
4182,
Further
information
is
available
from
http://www.auditcommission.gov.uk/nfi/fpindex.asp
When completed, please return this application form to:
London Borough of Merton
Parking Services
Civic Centre
London Road
Morden SM4 5DX
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