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Blue Badge
Application Form
Unable to walk or
virtually unable to walk
Please complete all relevant sections of the application form and supply the appropriate
documents to conrm your address, identity and evidence of eligibility. When completing
this form you may nd useful information on Blue Badge eligibility at: www.mygov.scot/
apply-blue-badge/eligibility.
The local authority may refuse to issue a badge if you do not provide adequate evidence
that the eligibility criterion is met.
If you are completing the form on behalf of an applicant who is under 16 years old or is unable to
complete the form themselves, please provide their details in the appropriate sections and sign the
form on their behalf.
Information about the applicant
Title (Mr, Mrs, Ms, other)
First name(s) (in full)
Surname
Surname at birth
(if different)
Date of birth
(DD/MM/YYYY)
M Y YD M Y YD
Place of birth
(town and country)
National Insurance
Number (16 and over)/
NHS Number (under 16
The NHS number is made
up of 10 digits, usually
shown in a 3-3-4 format)
Driving Licence Number
(if applicable)
Current address &
postcode
'Î1,(,%-0
%0&%
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Information about the applicant
Previous address,
if different in the last
three years
Telephone (home)
Telephone (mobile)
Email address
Do you currently hold
a Blue Badge, or have
you held a Blue Badge
before?
Yes No
if yes:
Which local authority issued you with the last badge?
What is the serial number on the last badge? (The serial number can
be found on the front of your badge.)
What is the expiry date of the last badge?
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Information about the applicant
Proof of your address We need to check that you are a resident in this local authority area
before we can process your application. Please select one of the
following options and provide copies of the original documentation
where relevant:
Either I have enclosed a Council Tax bill bearing my name
and address, dated within the last 12 months
Or I have enclosed a utility bill bearing my name and
address, dated within the last 3 months
Or I do not pay Council Tax, am over the age of 16 and
submit a copy of my lease as proof of my address
Or I give consent to the local authority to check my personal
details on the local authority’s Council Tax/Assessor and
Electoral Register or National Entitlement Card systems
to conrm my address
Or I am applying on behalf of an applicant who is under
16 and submit a copy of an NHS letter to prove their
address
Or I am applying on behalf of an applicant who does not pay
Council Tax and is under the age of 16. I give my consent
to the local authority to check school records to conrm
their address.
The name of the applicant’s school is:
Proof of your identity We need to check your identity to reduce the potential for fraudulent
applications for a Blue Badge. You must attach a photocopy of one of
the following as proof of your identity. Do not send original documents
as these will not be returned.
Birth/Adoption certicate
Marriage/Divorce certicate
Passport
Civil Partnership/Dissolution certicate
Valid driving licence
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Photograph
Please enclose a recent passport-quality photograph of the applicant. The photograph needs to
show the applicant’s full face so that the holder can be easily identied. No one else should be in
the photograph.
Applicants who are unable to access photo booths can provide a suitable clear photograph
taken by other means (*e.g mobile phone, tablet or digital camera) which can be cut down to
an appropriate size.
Please ensure that the applicant’s name is on the back of the photograph and complete the
declaration at the back of the form to conrm that the photograph is a true likeness.
Badge Fee
If your application is successful you will receive a letter/email/telephone call requesting payment
of £20 for your badge. Your Local Authority will only issue successful applicants with a Blue Badge
once payment has been received.
Payment information specic to Fife Council
We will let you know how you can pay for your badge when we advise that your application has
been successful.
Where possible, please nominate the
vehicle registration number(s) for the
main cars in which you intend to use
the Blue Badge:
(Up to three registration numbers should
be nominated, but please remember that
other vehicles can be used)
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Conrming your eligibility
Please note that you will only qualify for a Blue Badge under this criterion if you, or the person on
whose behalf you are applying, are over two years of age and:
• have a permanent and substantial disability which means you/they are unable to walk or
virtually unable to walk; (a permanent disability is one that is likely to last for the duration of
your life,) or
• have a temporary, but substantial disability, which means you/they are unable to walk or
virtually unable to walk which is likely to last for a period of at least 12 months, but less than 3
years.
1. Please select one of the following to conrm why you would benet from a Blue Badge:
I am unable to walk, or virtually unable to walk due to a permanent and substantial disability.
I am unable to walk, or virtually unable to walk by reason of a temporary but substantial
disability which is likely to last for a period of at least 12 months, but less than 3 years.
2. Please provide the name of the medical condition(s) or disability/disabilities which have led
to your Blue Badge application.
3. Do you have a terminal illness that seriously limits your mobility?
Yes No
4. Are you currently receiving care and support from palliative care services such as
Macmillan Cancer Support?
Yes No
5. Have you been issued with a DS1500 or BASRiS form?
Yes No
I can conrm I have attached a copy of my DS1500 or BASRiS form.
6. Please describe any surgery or courses of treatment you have undergone or specialist
clinics you have attended in relation to improve the conditions that make your walking
difcult.
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Conrming your eligibility
7. Please state when you underwent any relevant surgery or treatment or attended
specialist clinics.
Surgeries/courses of treatment/specialist clinic Dates you received this treatment
8. What medication do you currently take in relation your breathing or walking difculties?
Medication Dosage Frequency
Should you wish to provide a recent prescription to support your application, you may do so.
I have attached a recent prescription to support my application:
Yes
9. Are you currently
taking any pain relief
to improve your ability
to walk?
Yes No
If yes, please explain what you are taking and how frequently have
you been prescribed to take it.
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Conrming your eligibility
10. Are you currently...
Awaiting surgery in relation to the conditions/disabilities described
above?
Recuperating from surgery in relation to the conditions/disabilities
described above?
Awaiting treatment for any of the conditions/disabilities described
above?
Managing your condition/disability since you have been advised it
is not expected to improve any further?
None of the above.
11. Please give details of the regulated healthcare professionals, or specialists (including
your GP) who have been treating you in relation to the conditions/disabilities described
above:
Name Job Title Hospital/Health Centre Phone Number
12. Have you been advised by a regulated health professional that walking is benecial for
you?
Yes No
13. Have you been advised by a regulated health professional that walking is detrimental or
dangerous for you? If so, please provide their details in the table above.
Yes No
If you ticked Yes, please provide details of their advice:
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Conrming your eligibility
14. Do you anticipate that your conditions/disabilities will improve in the next 3 years?
Yes No
If you ticked Yes, please describe how much you expect your conditions/disabilities to improve:
15. Please tick all
of the following
statements that
describe your general
walking ability
I am able to walk well, including recreational walk.
I am able to walk around the supermarket to do my own shopping.
I am able to walk and can use public transport for some of my
local trips.
I am able to walk, but struggle with longer distances or hills.
I am able to walk, but get severe breathless related to my medical
condition(s) if I walk for more than a few minutes.
My level of pain causes me to stop walking more often than not.
I am able to walk around my home, but am unable to climb the
stairs.
I am a full-time wheelchair user.
Other, please describe below:
16. Are you able to walk outside alone (not including the use of a walking aid), or do you need
someone to assist you?
Yes No
If No, please describe the help you need below:
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Conrming your eligibility
17. Where, in your local area, can you comfortably walk to before you feel discomfort?
This could be from your home or another specic location.
(Please state each specic location or landmark which could be found on a map, e.g. a shop,
street address or park) *Local Authorities can check this on via an online mapping tool to provide
them with an accurate distance.
18. Please tick the box
that best describes the
way you walk
No specic problems with walking.
You walk with a slight limp.
You walk with a heavy limp, a stiff leg or shufe, or have
problems with balance.
You drag your leg, stagger, swing through two crutches or need
physical support.
If there is not a box that describes the manner of your walking
(your gait), please tell us in your own words about the way you
walk in the space provided below, if pain impacts on your gait
please include details on the location and nature of the pain:
19. Have you been
seen by a healthcare
professional in the past
12 months due to falls?
Please provide details:
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Conrming your eligibility
20. Do you use any of
the following walking
aids?
1 elbow crutch
2 elbow crutches
1 walking stick
2 walking sticks
Walking frame/Zimmer
Rollator (walking frame with wheels)
Wheelchair
Powered wheelchair
Other, please describe below:
21. Were your walking
aids...
Purchased privately by me
Prescribed by a healthcare professional
Provided by Social Services
Other (please describe below)
Wheelchair users:
If you selected ‘wheelchair’ above, please answer the following 3 questions:
22. Please tick which
applies to you:
Wheelchair
Powered wheelchair
23. Was your
wheelchair:
Purchased privately by me
Prescribed by a healthcare professional
Provided by Social Services
Other (please describe below)
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Conrming your eligibility
24. Do you use your wheelchair all the time, indoors & outdoors?
Yes No
If No, please describe when you use your wheelchair and explain why?
Please answer ‘Yes’ or ‘No’ to each of the following questions:
25. Do you get severe breathlessness or struggle to hurry on at ground or to walk up a slight
incline/hill, due to a medical condition?
Yes No
26. Do you need to pause for breath after walking a short distance on at ground?
Yes No
27. Do you struggle to walk and talk at the same time?
Yes No
28. Do you get severe breathlessness related to a medical condition in the house when
walking from room to room?
Yes No
29. Is there anything else you would like to add that you think is relevant in support of
your application for a Blue Badge? Please note you can also attach copies of consultant,
result, hospital discharge and prescriptions letter or patient summaries.
I have attached medical letters/documentation to support my application:
Yes
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Declarations and Signatures
These questions are intended to be answered by all Blue Badge applicants.
Please read the following declarations thoroughly and tick all of the relevant boxes to indicate that
you have read and understood each declaration. Not ticking one of these declarations may mean
we are unable to issue you with a Blue Badge. Providing fraudulent information may result in
prosecution and a ne.
All documents relating to this application will be dealt with in line with the Data Protection Act 2018,
UK General Data Protection Regulation (GDPR) and may be shared within the local authority, with
other local authorities, the police and parking enforcement ofcers to detect and prevent fraud. We
also have our own Privacy Policy, details of which can be found on our website.
Any medical information that you have supplied to support this application is deemed, under the
Data Protection Act 2018, to be “sensitive personal data” and will only be disclosed to third parties as
necessary for the operation and administration of the Blue Badge scheme, and to other government
departments or agencies, to validate proof of entitlement or as otherwise required by law.
Declarations to be completed by applicant
I can conrm that, as far as I know, the details I have provided are complete and accurate.
I understand that action may be taken against me if I have provided false information in this
application form.
I understand that I must promptly inform my local authority of any changes that may affect
my entitlement to a Blue Badge.
I conrm that the photograph I have submitted is a true likeness.
I understand that, if my application is successful, I must not allow any other person to use
the Blue Badge and I must only use the Blue Badge in accordance with the rules of the
scheme as set out in the Rights and Responsibilities leaet that will be sent to me with my
Blue Badge.
I understand I must not hold more than one valid Blue Badge at any time.
I consent to the local authority contacting a regulated healthcare professional for the
purpose of obtaining further information in support of my application.
I understand that I may be required to undertake an assessment with a regulated healthcare
professional who is independent of my existing care and treatment, in order to determine my
eligibility for a Blue Badge.
I consent to the local authority having access to my medical notes where their systems allow.
Misuse of a Blue Badge is a criminal offence.
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Your consent to use your information to improve the service you receive
Please read and tick the following declarations that you consent to. Ticking these boxes will help
us to improve the service we can offer.
I consent to my local authority checking any information already held by their Social
Services department on the basis that:
• It can help determine my eligibility for a Blue Badge.
• It may speed up the processing of my application.
• It may enable a decision to be made without the need for a mobility assessment.
I agree to the disclosure of information included in this form to other local authority
department/service providers so that I can be informed about other services that may
be of benet to me.
Checklist of documents you may need to disclose
Please ensure that you have enclosed copies of all of the relevant documents for the sections
of this application form. Copies should be true likeness of the originals. Please tick the relevant
box(es) below to conrm all documents/photocopies provided are genuine:
Copy of letter from your Doctor or Healthcare Specialist to support your application,
including any other supporting medical documentation
Copy of your DS1500 form or BASRiS form, if applicable
Copy of a recent prescription, if applicable
Document to prove your address, as listed in the ‘Information about the applicant’ section
Document to prove your identity, as listed in the ‘Information about the applicant’ section
Your signature against the declarations
Applicant’s signature
Date of application
(DD/MM/YYYY)
M Y YD M Y YD
Please print your name
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Submitting your application
Postal applications should be sent to
Blue Badge Team
Fife Council
Bankhead Central
Bankhead
Glenrothes
KY7 6GF
You can hand in your application at any of Fife Council’s Customer Service Centre.
Telephone our Contact Centre on 03451 550066 if you require further information.
