Blue Badge Application Form

Automatic Eligibility

Please complete all relevant sections of the application form and supply the appropriate documents to confirm your address, identity and evidence of eligibility. When completing this form you may find 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’s 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): D D M M Y Y Y Y

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:

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?

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 confirm 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 confirm 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 certificate
• Marriage/Divorce certificate
• Passport
• Civil Partnership/Dissolution certificate
• Valid driving licence

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 identified. 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 confirm 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 specific to Orkney Islands Council

The fee for a new badge or renewal is £20.00. Payment can be made by cash, cheque, postal order or debit or credit card. Cheques should be made payable to: Orkney Islands Council. Payment will only be taken if your application for a Blue Badge is successful. You will only be issued with a Blue Badge once your payment has been received.

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.)

Confirming your eligibility

The following questions are intended for people who may qualify for a Blue Badge automatically because they:

• are blind (severely sight impaired);
• receive the higher rate of the mobility component of Disability Living Allowance;
• receive the mobility component of Personal Independence Payment awarded at 12 points for a “planning and following journeys” or awarded at 8 points or more for “moving around”;
• receive the higher rate mobility component of Child Disability Payment;
• receive the mobility component of Adult Disability Payment and have been awarded either:
  • 8 points or more in the Moving Around activity;
  • 12 points in the Planning and Following a Journey activity;
  • enhanced rate mobility without reference to points;
• receive the War Pensioner’s Mobility Supplement; or
• receive a qualifying award under the Armed Forces and Reserve Forces (Compensation) Scheme.

People who are blind (severely sight impaired)

1. Are you registered as blind (severely sight impaired)?

   • Yes
   • No

   If YES, please state which local authority you are registered with:

   Do you give consent for us to check our local authority register of blind and partially sighted persons, to confirm if your disability is already known to the council?

   • Yes
   • No

   If no, you must enclose a copy of your Certification of Blindness or Defective Vision BP1 (3R) or Certificate of Vision Impairment (CVI) or a previous equivalent, signed by a Consultant Ophthalmologist and held by your Social Services Department or local society.

   I can confirm I have attached the required document:

   • Yes

People who receive the Higher Rate of the Mobility Component of Disability Living Allowance

2. Do you receive the higher rate of the mobility component of Disability Living Allowance?

   • Yes
   • No

   If YES, have you been awarded this benefit indefinitely?

   • Yes
   • No

   If NO, when is your award of this benefit due to end?

   D D M M Y Y Y Y

   You must enclose a copy of your Higher Rate of the Mobility Component of Disability Living Allowance entitlement letter, showing the end date of your award – either a letter issued in the last 12 months or a copy of your original annual uprating letter. If you have lost your award or uprating letter please contact DWP for a current letter.

   I can confirm I have attached the required document:

   • Yes

People who receive 8 Points in the Moving Around Activity or 12 Points in the Planning and Following a Journey Activity of PIP

3. Have you been awarded this benefit for an ongoing period?

   • Yes
   • No

   If NO, when is your award of this benefit due to end?

   D D M M Y Y Y Y

   You must enclose a copy of your entitlement letter which shows either your ‘Moving Round’ or ‘Journey Planning’ descriptor. The letter must show the end date of your award and either be a letter issued in the last 12 months or a copy of your original annual uprating letter. If you have lost your award or uprating letter please contact DWP for a current letter.

   I can confirm I have attached the required document:

   • Yes

People who receive Child Disability Payment

4. Do you receive the higher rate mobility component of Child Disability Payment?

   • Yes
   • No

   If YES, does your Child Disability Payment have a review date?

   • Yes
   • No

   If YES, when is your award due to be reviewed?

   D D M M Y Y Y Y

You must enclose a copy of your Child Disability Payment decision letter or your Certificate of entitlement.

I can confirm I have attached the required document:

• Yes

People who receive 8 Points in the Moving Around Activity or 12 Points in the Planning and Following a Journey Activity of Adult Disability Payment

You can find information on your points in the Mobility Needs section of your Adult Disability Payment decision report.

5. Does your Adult Disability Payment have a review date?

   • Yes
   • No

   If YES, when is your award due to be reviewed?

   D D M M Y Y Y Y

   You must enclose a copy of your Adult Disability Payment decision letter and the Mobility Needs page from your decision report showing your mobility points.

   Alternatively, you can enclose a copy of your Certificate of entitlement.

   I can confirm I have attached the required document:

   • Yes

People who receive Adult Disability Payment without reference to points

6. Do you receive the enhanced rate mobility component of Adult Disability Payment? You can find this information in your Adult Disability Payment decision letter.

   • Yes
   • No

   Did you receive an Adult Disability Payment decision report listing your mobility points?

   • Yes
   • No

   Does your Adult Disability Payment have a review date?

   • Yes
   • No

   If YES, when is your award due to be reviewed?

   D D M M Y Y Y Y

You must enclose a copy of your Adult Disability Payment decision letter or your Certificate of entitlement.

I can confirm I have attached the required document.

• Yes

People who receive the War Pensioner’s Mobility Supplement

7. Do you receive the War Pensioner’s Mobility Supplement?

   • Yes
   • No

   If YES, have you been awarded this benefit indefinitely?

   • Yes
   • No

   If NO, when is your award of this benefit due to end?

   D D M M Y Y Y Y

You must enclose a copy of your original letter of entitlement to this benefit. You should have an award letter from the Service Personnel and Veterans Agency (SPVA). Please contact the SPVA if you have lost your letter.

I can confirm I have attached the required document:

• Yes

People who receive a benefit under the Armed Forces and Reserve Forces (Compensation) Scheme

8. Have you received a lump sum benefit under the Armed Forces and Reserve Forces (Compensation) Scheme within tariff levels 1 – 8 (inclusive) and have you been certified by the SPVA as having a permanent and substantial disability which causes inability to walk or very considerable difficulty walking?

• Yes
• No

You must enclose a copy of your original letter of entitlement to this benefit. You should have an award letter from the Service Personnel and Veterans Agency (SPVA). Please contact the SPVA if you have lost your letter.

I can confirm I have attached the required document:

• Yes

Declarations and Signatures

The following questions are mandatory and 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 fine.

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 officers 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 confirm 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 confirm 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 leaflet 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.

Misuse of a Blue Badge is a criminal offence.

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 benefit 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 confirm all documents/photocopies provided are genuine:

• Certification of Blindness or Defective Vision BP1(3R) or Certificate of Vision Impairment (CVI)
• Higher Rate of the Mobility Component of Disability Living Allowance entitlement letter
• PIP entitlement letter which shows either your ‘Moving Around’ or ‘Journey Planning’ descriptor
• Child Disability Payment decision letter or Certificate of entitlement
• Adult Disability Payment decision letter and Mobility Needs page from your decision report (if you have one). Or, your Adult Disability Payment Certificate of entitlement
• War Pensioner’s Mobility Supplement letter
• Armed Forces and Reserve Forces (Compensation) Scheme letter
• 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): D D M M Y Y Y Y

Please print your name:

Submitting your application

Please return this form and relevant documents to:

Customer Services (Blue Badge Application)
Orkney Islands Council
Council Offices
School Place
Kirkwall
Orkney
KW15 1NY

IMAGE: The first page shows the Blue Badge Application Form for Automatic Eligibility, with the Orkney Islands Council crest and the Transport Scotland logo. The visible logo text reads “ORKNEY ISLANDS COUNCIL” and “TRANSPORT SCOTLAND COMHDHAIL ALBA”.