Apply for a Blue Badge

Please use this form to apply for yourself or someone else.

A Blue Badge costs £10, and you can make payment online or by

cheque. Once an application is approved:

• If you include an email address in this form, you will be

asked to make online payment by credit/debit card.

• If you do not include an email address, you will receive a

letter requesting cheque payment to be submitted by post.

You’ll need to provide proof of identity, address and benefit (if

applicable). Along with a recent passport sized photograph of the

applicant’s face including shoulders.

The local authority may refuse to issue a badge if you do not

provide adequate evidence that you meet the eligibility criteria.

You can apply online by visiting: gov.uk/apply-blue-badge

Who are you applying for?

Myself (The badge is for you)

Someone else (A relative or somebody you care for)

Fill in the answers and sign the form on their behalf. Where

the form says “you”, it is referring to the applicant.

If you’re applying for

somebody else, we’ll ask

for your name and your

relationship to the

applicant.

If applying for a child

under 3, please go to

Section 6 once you have

completed Section 1.

Do you already have a Blue Badge?

Yes

Enter the badge number (6 digits)

If you don’t know the

badge number, leave it

blank and your local

authority should be able

to find the badge using

your details.

Full name (First name and Last name)

Should be the full name

of the person the badge

is for.

Section 1 – Applicant details

Return completed form to:

oncessionary Travel

PO Box 55290

London

N22 9GA

Has your name changed since birth?

Yes

Enter full name at birth

Gender

Man (or Boy)

Woman (or Girl)

Identify in a different way

Enter gender identified with

Date of birth (Day / Month / Year)

National insurance number

(Leave blank if you don’t have one)

This helps us to find your

details if you call up about

your application.

Postal address

(This is where the badge will be posted to)

Email address (optional)

If you include an email

address, we will use this

for all future

correspondence. You will

also be requested to

make payment online

using credit/debit card.

If you do not have an

email address, we will

continue to write to you

by letter.

Main phone number (required)

Including the applicants

telephone number helps

enforcement officers

check the badge is being

used correctly.

Alternative phone number (optional)

Nominated vehicle registration number

If you have a vehicle

which you will regularly

use with your blue badge,

please tell us here. This

will help us to allow you

to park if your badge is

lost, stolen or damaged.

Who should be contacted about this application?

(If you’re the contact, put your full name here)

Your relationship to the applicant

If you are applying on behalf of somebody else

Which of these are you providing as proof of identity?

(Choose one, to attach as a certified copy)

Birth or adoption certificate

Marriage / Civil partnership / Dissolution or Divorce certificate

Passport

Driving licence

Attach a certified copy

of the proof of identity to

this application.

Do you give the local authority permission to check their

records to prove your address?

Yes

Which records should we check? (Choose one)

Council tax / Electoral roll / School records

You must provide a copy of your proof of address

Recent photograph of the applicant

You’ll need a colour passport size photo to be printed on the back

of the Blue Badge. The requirements are similar to a passport

photo.

Make sure it:

- Has a plain, light, background

- Includes face and shoulders

- Shows the face clearly

- Is a true likeness

If you don’t give us

permission. You must

attach a copy of either:

- Council tax

- Driving licence

- School records

- Benefit letter

It’s best to get somebody

else to take the photo.

The photo should have

the applicant’s name and

a signature on the back.

For you or the person you’re applying for

Vehicle Registration

Do you drive yourself, or do you normally travel in a specific motor

vehicle?

Yes

Enter the vehicle registration number

If there is no main vehicle you travel in, please select

this option

The vehicle could be

owned by the applicant,

or one that is owned and

driven by their main carer

e.g. their partner/spouse

or their parent/carer.

Blue Badges can be used

in any motor vehicle the

holder is travelling in.

Badge issue fee

The local authority will explain how payment should be made, if the

application is successful.

A Blue Badge costs up to

£10 in England and £20

in Scotland. It’s free in

Wales.

You may automatically qualify for a Blue Badge if you either:

• Are severely sight impaired (blind)

• Received 8 or more points in the “moving around” part or 10

points (Descriptor E) in the “planning and following journeys”

part of a mobility assessment for Personal Independence

Payment

• Receive the higher rate of the mobility component for

Disability Living Allowance

• Receive the War Pensioners’ Mobility Supplement

• Receive a qualifying award under the Armed Forces

Compensation Scheme

If none of these apply to you, go to Section 3. Otherwise, you

should complete the relevant section below and then go to Section

Unless you are registered

as severely sight

impaired (blind), you will

need to attach a copy of

the proof of your benefit

to this application.

Are you registered as severely sight impaired (blind) and do

you give us permission to check the register at the local

authority?

If you are not registered

as severely sight

impaired (blind) and you

would like to be, let us

know and provide a copy

us with of your Certificate

of Vision Impairment.

Section 2 – Benefits or severely sight impaired

Severely sight impaired (blind)

Yes

Enter the name of the local authority you are registered to

Enclose a copy of your Certificate of Vision Impairment (CVI)

Were you awarded the higher rate of the mobility component?

Yes

If your award has an end date, enter the end date

You should answer the questions in Section 3

If you were awarded the higher rate of the mobility component, you

need to attach a copy of the letter from DWP, dated within the last

12 months. This certificate of entitlement should confirm your

mobility rating.

Make sure you send a

copy of the award letter

with this application.

Did you score 8 points or more in the “moving around” part of

the mobility assessment?

Yes

How many points were scored?

If your award has an end date, enter the end date

No Answer the next question under “PIP”

If you did score 8 points or more in the “moving around” part of the

mobility assessment, you need to attach a copy of every page from

Make sure you send a

copy of all of the pages

from the award letter with

this application.

Disability Living Allowance (DLA)

Personal Independence Payment (PIP)

the award letter from DWP. It should show your entitlement to PIP,

assessment scores (including the mobility scores).

Did you score this specific points descriptor in the “planning

and following a journey” part of the mobility assessment?

Descriptor E (10 points) - You cannot undertake any journey

because it would cause overwhelming psychological distress

Yes

If your award has an end date, enter the end date

You should answer the questions in Section 3

If you did score the 10 points outlined above in the “planning and

following journeys” part of the assessment, you need to attach a

copy of every page from the award letter from DWP. It should show

your entitlement to PIP, assessment scores (including the mobility

scores).

Make sure you send a

copy of all of the pages

from the award letter with

this application.

Have you received a lump sum payment within tariff levels 1 to

8 of the scheme?

and have you been certified as having a permanent and substantial

disability?

Yes

Enclose the original letter from Veterans UK* as proof.

You must enclose the

original version of your

letter as proof of

entitlement.

*Letters were previously

issued by the Service

Personnel and Veterans

Agency (SPVA)

Do you receive the War Pensioners’ Mobility Supplement?

You must enclose the

original version of your

letter as proof of

entitlement.

Personal Independence Payment (PIP)

Armed Forces Compensation Scheme

War Pensioners’ Mobility Supplement

Yes

If your award has an end date, enter the end date

If you answered “yes” to any of the questions in section 2, go

straight to Section 7.

Do you have a condition or disability which means you cannot

walk or find walking very difficult?

Yes

Continue answering the questions in this section

Go to Section 4

Remember, when we are

referring to “you” this is

the applicant. If you’re

applying for somebody

else, answer the

questions on their behalf.

Name any health conditions or disabilities that affect your

walking

(Try to use the correct medical terms, if you know them)

Be as descriptive as

possible, but we’ll ask

you some more questions

after this about how your

walking is affected and

things like medication.

Section 3 – Walking difficulties

How does your health condition make walking difficult for you?

Excessive pain

If you didn’t tick “Excessive Pain”, don’t answer this section.

How would you describe the pain you experience, when

walking? (You can choose more than one)

When I take my pain relief medication, I am able to cope w

the pain

Even after taking pain relief medication, I have to stop and

take regular breaks.

Even after taking pain relief medication the pain makes m

physically sick

Even after taking pain relief medication I am frequently in

much pain that walking for more than 2 minutes is unbear

Other

Describe the pain

Breathlessness

If you didn’t tick “Breathlessness”, don’t answer this section.

When do you get breathless?

(You can choose more than one)

Walking up a slight hill

Trying to keep up with others on level ground

Walking on level ground at my own pace

Getting dressed or trying to leave my home

Other

Describe when you get breathless

Only fill in the extra

textboxes if you’ve ticked

the checkbox.

Also known as shortness

of breath, this could be

described as an intense

tightening in the chest, or

a feeling of suffocation.

Balance, coordination or posture

Describe how the way you walk is affected by your condition

(For example, if your posture is affected or you struggle to

take full steps)

How would you describe your balance or coordination,

when walking?

(You can choose more than one)

I can walk around a supermarket, with the support of a tro

I can walk up/down a single flight of stairs in a house

I can only walk around indoors

I can walk around a small shopping centre

Other

Describe your balance or coordination, when walking

Have you seen a healthcare professional for any falls in the

last 12 months?

Yes No

It's dangerous to my health and safety

Describe how your condition makes walking dangerous

Do you have a chest, lung or heart condition / epilepsy?

Yes No

Something else

What is it about your condition that causes you difficulty

walking?

Only fill in the extra

textboxes if you’ve ticked

the checkbox.

What is this aid or support?

(For example, a wheelchair, crutches or a

member of your family)

When do you need

this help?

(For example, to get to

the shops)

If it's an aid, how was it

provided?

(For example, Hospital

or bought privately)

How long can you walk for without stopping?

(If you listed an aid, then your answer should be when using that

aid)

I can't walk at all

Less than a minute

Between 1 and 5 minutes

Between 5 and 10 minutes

More than 10 minutes

“Stopping” could be to

take a rest or to catch

your breath.

Only tick one.

Help to get around

Describe somewhere you can walk from and to

(Be specific and use place names or house numbers)

For example, “from my

home to Tesco” or “from

my home to No. 36 on my

street”

How long does it take you?

(For example, 8 minutes)

You can now go to: Section 7 – Treatments, medication,

healthcare professionals & supporting documents

If you use an aid to get

around, then your answer

should be whilst using

that aid

If you answer "no" to the first question in this section, but “yes” to

any of the questions in section 3, you can skip this section and go

straight to Section 7.

Do you have a non-visible (hidden) condition, causing you to

severely struggle with journeys between a vehicle and your

destination?

Yes

Continue answering the questions in this section

Go to Section 7

Remember, when we are

referring to “you” this is

the applicant. If you’re

applying for somebody

else, answer the

questions on their behalf.

What affects you taking a journey?

(Tick all that apply)

I am a risk near vehicles, in traffic or car parks

When are you a risk?

Almost never

Sometimes

Almost every journey

Every journey

If some, or most, of these

do not apply to you,

please use the free text

boxes to explain what

affects you.

If you cannot walk, go to section 7

Section 4 – non-visible (hidden) conditions

Please give an example of when you have been a risk near

vehicles, in traffic or car parks

I struggle to plan or follow a journey

What journeys does this apply to?

Unfamiliar journeys Every journey

I find it difficult or impossible to control my actions and lack

awareness of the impact they could have on others

How often does this happen?

Almost never

Sometimes

Almost every journey

Every journey

Remember, when we are

referring to “you” this is

the applicant. If you’re

applying for somebody

else, answer the

questions on their behalf.

Please describe the kinds of incidents that have happened or

are likely to happen on journeys

I regularly have intense responses to overwhelming situations

causing temporary loss of behavioural control

How often does this happen?

Almost never

Sometimes

Almost every journey

Every journey

Please give examples of the situations that cause temporary

loss of behavioural control

I can become extremely anxious or fearful of public/open

spaces

When do you become extremely anxious/fearful?

Almost never

Sometimes

Almost every journey

Every journey

Please describe the levels of anxiety

Something else

Please describe what affects you taking a journey

How would a Blue Badge improve taking a journey between a

vehicle and your destination for you?

(Describe your needs, in detail)

What measures are currently taken to try to improve journeys

for you between a vehicle and your destination?

(List the measures taken to try to improve journeys)

Remember, when we are

referring to “you” this is

the applicant. If you’re

applying for somebody

How effective are they?

else, answer the

questions on their behalf.

If you answer "no" to the first question in this section, but

“yes” to any of the questions in sections 3 or 4, you can go

straight to Section 7.

Do you have a disability in both arms?

Yes

Continue answering the questions in this section

Go to Section 6

Remember, when we are

referring to “you” this is

the applicant. If you’re

applying for somebody

else, answer the

questions on their behalf.

Do you drive regularly?

Yes

Continue answering the questions in this section

Go to Section 6

Name any health conditions or disabilities that affect your

arms

(Try to use the correct medical terms, if you know them)

Section 5 – Disability that affects both arms

Do you struggle to operate parking machines?

Yes

Describe how you struggle to operate parking machines

Do you drive an adapted vehicle?

Yes

Describe how it has been adapted for you. You should also

attach copies of insurance details or Vehicle Registration

document which verify this.

Attach copies of your

insurance details or

Vehicle Registration

document as supporting

documents.

This section is for people applying on behalf of a child that is under

3 years old.

Are you applying for a child under 3 years old?

Yes

Continue answering the questions in this section

Go to Section 7

Which of these applies to the child under 3?

They need to be accompanied by bulky medical equipment

They need to be near a vehicle to receive or be taken for

treatment

Neither of these

Name any health conditions or disabilities that affect the child

(Try to use the correct medical terms, if you know them)

You should enclose a

letter from any healthcare

professionals that are

involved in the child’s

treatments, which

confirms the details of the

condition.

Section 6 – Children under 3 years old

This section is for if you have answered any of the questions in

sections 3, 4, 5 or 6. Otherwise, go to Section 9.

Has your condition required any treatments?

These could have been in the last 10 years, ongoing or any

treatment you have booked in the next 3 years. List any surgeries,

treatments or clinics that are to do with your condition.

Yes

Add the treatment details below

Go to “Medication”

Remember, when we are

referring to “you” this is

the applicant. If you’re

applying for somebody

else, answer the

questions on their behalf.

Treatments

Section 7 – Treatments, medication, associated

professionals & documents

Describe the treatment

Anything relevant to your condition that you've seen (or are

due to see) a professional for. For example, hip replacement

operation, physiotherapy or pain clinic.

Date of the treatment

If it’s in the future – Do you

expect the condition to improve

afterwards?

Do you take any medication for your condition?

(Any medication or pain relief you currently take for your condition)

Yes

Add the medication details below

Go to “Associated professionals”

Treatments

Medication

Name of this medication or pain relief

And is it prescribed?

How much do you

take at a time?

(Dosage)

How often do you take

this?

Do you currently see any professionals for your condition?

(Or if you have seen any in the last 3 years)

Yes

Add their details below

Go to “Supporting documents”

Examples of

professionals could be

consultants, teachers,

therapists, neurologists,

psychologists, or

psychiatrists

Medication

Associated or healthcare professionals

Name and role of the professional

(This cannot only be your GP)

Where do they work?

(Include organisation name, address, email

and telephone number if possible)

Are you attaching supporting documents to this application?

Yes

List the documents you are attaching below.

Go to Section 9

It’s especially important to

attach documents where

we’ve asked for you to

provide proof or

verification.

Associated or healthcare professionals

Supporting documents

Sign one of the two sections.

By submitting this application you agree that:

• you have read and understand the rules for using a Blue

Badge

• the details provided are complete and accurate

• you won't hold more than one Blue Badge at any time

• you will tell your local authority about any changes that may

affect your eligibility

You also agree that your local authority may:

• contact you if there are any issues with this application or to

prevent badge misuse

• if required, arrange a phone-based or in-person assessment

for you

• check your eligibility with the information they hold

• suggest other benefits or services that you may be eligible

for

I agree to this declaration

Signed

Date of signature

Read the declaration

carefully and only sign it

once you are clear.

By submitting this application you agree on behalf of the applicant

that:

• the rules for using a Blue Badge have been read and

understood

• you have the authority to submit this application

• the details provided are complete and accurate

• they won't hold more than one Blue Badge at any time

• your local authority will be told about any changes that may

affect their eligibility

•

You also agree that your local authority may:

Read the declaration

carefully and only sign it

once you are clear.

Applying for yourself

Section 9 – Declaration

Applying on behalf of somebody else

•

contact the person whose details have been provided if there

are any issues with this application or to prevent badge

misuse

• if required, arrange a phone-based or in-person assessment

for the applicant

• check their eligibility with the information they hold

• suggest other benefits or services that they may be eligible

for

I agree to this declaration

Signed

Date of signature

DATA SECURITY STATEMENT:

We will use the information we collect on this form and from supporting evidence to

process your appl

ication for a Blue Badge. We may check the information you

provide, or the information about you which somebody else has provided with this

form with other information we hold. We may also request information from other

people or organisations or share information with them to check the accuracy of

Information provided about you, to prevent or detect crime, or to protect public

funds we administer. These include other people and organisations, government

departments and local authorities.

We will not give information about you to anyone outside Haringey Council, or use

information about you for other purposes, unless the law allows us to.