Form BB1

Application for a disabled person’s parking badge

You should return this form to the Hampshire County Council Blue Badge Unit.
Please read the accompanying 'BB1a notes' before completing the form. This information will help you to answer the questions correctly.
Throughout the application form there are links to the relevant section in the BBla notes. You can access these notes by clicking on the appropriate link.
(To return to this application you must use the back button on your browser to prevent you losing information already completed.)
Complete this form online and print using your browser's printing options or the print button at the end of the form.
Please ensure that all the text fields you have completed are visible when you print the form.

Part 1: Your personal details

Please give details of the person applying for the badge (Please see the relevant section in BB1a notes). If you are applying for somebody else, please give his or her details here and complete section 2.

1	Your surname

2	Your first names

3	Your title
	If 'other' please give details

4	Your date of birth

5	Your postcode

6	Your address

7	Your home telephone

Part 2: Personal details of the applicant’s representative, if appropriate

(Please see the relevant section in the BBla notes )

8	Surname

9	First names

10	Title
	If 'other' please give details

11	Postcode

12	Address

13	Home telephone number

14	Relationship to the person applying for the badge

Part 3: Automatic qualification for a badge

15	Are you registered as blind by a local authority under the National Assistance Act 1948?
		Yes	No

	Please send a copy of your blind registration card.

16	Do you receive mobility allowance or the higher rate of the mobility component of Disability Living Allowance?
		Yes	No

	Please send either an official letter confirming that you receive the allowance, a Vehicle Excise Duty Exemption certificate, or a Post Office Order Book showing details of the allowance.


17	Do you receive a war pensioner’s mobility supplement or a similar mobility supplement paid by the Overseas Development Agency?
		Yes	No

	Please send an official letter confirming that you receive War Pensioner’s Mobility supplement or similar.

18	Was your vehicle supplied by the Department of Work and Pensions?
		Yes	No

	Please give details
	Please send official written evidence.

19	Do you receive a government grant towards the cost of your vehicle?
		Yes	No

	Please give details
	Please send official written evidence.

	If you have answered Yes to any of the questions above, please go to part 7. If not, please complete part 4.

Part 4: Discretionary qualification for a badge

20	Do you consider that you have a permanent and substantial disability that causes inability to walk or severe difficulty walking?
		Yes	No

		Go to question 21	Go to Part 5

21	What is your disability or illness?




22	How far can you walk without stopping, severe discomfort or help from someone else?


23	Do you regularly need to use a walking aid or wheelchair prescribed or recommended by a doctor (apart from a single walking stick)?
		Yes	No

	Please state what equipment you use

24	Is your disability expected to improve on its own or with surgery or therapy?
		Yes	No

	Please give details

Go to Part 6

Part 5: Severe upper limb disabilities

Complete this part only if you hold a valid driving licence and have a severe disability in both upper limbs and cannot turn the steering wheel of a vehicle by hand, even if a turning knob is fitted.

25 What is the nature of your disability?

26 Do you drive a specially adapted car?

Yes No

Please give details of the adaptation

Part 6: Doctor’s details

(Please see the relevant section in the BB1a notes)

If you have completed part 4 or 5, we may need information from your doctor to support your application. Please give the following information about your doctor.

27 Doctor’s name



28 Address of the doctor’s practice



29 Postcode of the practice



30 Telephone number



If we need more information to support your application, we will contact your doctor.

31
Are you willing to have a medical examination that would show how disabled you are and provide information to support your application?

Yes No

Part 7: Ethnic group

We use this information to make sure that people from all ethnic groups use our service – so that, if not, we can do something about it.

32
Please tick the box that you feel best represents your ethnic group.

British Chinese



Other European I do not want to give my ethnic group



Asian



African



Caribbean

Other Please give details

Part 8: Declaration and signature

The information I have given on this form is true and correct to the best of my knowledge. I understand that you may check any of the information I have given at any time.

I agree to the Blue Badge Unit contacting my doctor for more information about my disability, if this is needed to process my application.

Data Protection Act 1998
I/My representative understand that the Blue Badge Unit will store this information on paper and on computer, and I agree that when necessary it can be shared with other organisations that work with Hampshire County Council. I also understand that the Blue Badge Unit will keep the information secure and confidential and that I can ask to see information held about me at any time (in accordance with the Data Protection Act 1998).

Signed

Date

Please sign in the white space below.
This signature will go on your blue badge.

Please return your form to:
Blue Badge Unit
The Castle
Winchester
Hampshire
SO23 8UH

Have you: (Please see notes)
	signed the white label in Part 8?

	enclosed two recent passport-sized photographs (approximately 3.5cm x 4.5cm or 1.25" x 1.75"), signed on the back?

	enclosed a cheque or postal order for £2 made payable to Hampshire County Council?

Please see the relevant section in the BB1a notes

Office Use Box
Date application received			Client reference number
	Date GP form BB3 sent to GP
	Date completed form BB3 received		Badge number
	Date badge issued	Initials
	Date application refused		Badge expiry date
	Details entered on system
	Details entered on spreadsheet

25	What is the nature of your disability?

26	Do you drive a specially adapted car?
		Yes	No

	Please give details of the adaptation

27	Doctor’s name

28	Address of the doctor’s practice

29	Postcode of the practice

30	Telephone number

	If we need more information to support your application, we will contact your doctor.

31	Are you willing to have a medical examination that would show how disabled you are and provide information to support your application?

		Yes	No

		British		Chinese

		Other European		I do not want to give my ethnic group

		Asian

		African

		Caribbean

		Other Please give details