EXPRESS PIP HIGHER RATE BLUE BADGE APPLICATION

Dear {name} from the information you have provided it certainly seems like you could qualify for a Blue Badge. You will need to answer a few more questions in order for us to successfully submit a Blue Badge application for you.
The submission service fee for BBSS to officially submit your details through the correct government online gateway is £30 - would you like to continue?*

YesNo

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Thank you for your payment.

You are now able to complete the remainder of the Blue Badge questionnaire.

Please give us as much information as possible - There are no time limiters on this form.
Personal Details
Name

First NameLast Name followed by (surname at birth) if different in brackets
Gender
Date of Birth

DayMonthYear
Date
National Insurance Number
Address

Street Address

Street Address Line 2

City/TownState

PostcodeCountry
Email address*
Please ensure this email address is correct
Telephone Number
Medical Conditions
Please explain your mobility issues in detail and use medical terms wherever possible *
Have you fallen in the last 12 months and did you see a doctor

YesNo
What is the maximum distance you can walk using a walking aid, experiencing severe discomfort, or needing help from another person?
Yards/Metres
How many minutes can you walk for before you need to stop and have a rest, regain your breath or balance?
Minutes
Medication

Mobility Aids

Treatment

Do you expect your condition to improve after having this treatment?

YesNo

Do you expect your condition to improve after this appointment or having this treatment?

YesNo

GPs/Consultants details

Rows	GPs/Consultants Name	Name of Practice/surgery/hospital	Postcode	Telephone Number
1
2
3
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PIP - Higher Rate (8 points or more) - Physical Disability
Please enter the amount of points you receive
DLA - Awarded "Indefinitely"
Registered Blind (HSST)
Registered Severly Sight Impaired (CVI)
Impaired Both Arms
AFCS
WPMS
Terminally Ill (Has a DS1500 Form)

Declaration
You must read and complete this section to proceed with your application for a Blue Badge.
I declare that: *
I have read and understood the rules and regulations for using a Blue Badge
The details I have provided are complete and accurate
I will not hold more than one Blue Badge at any one time
I will inform the Blue Badge processing department/council of any change which I think may affect my eligibility.
I declare that: *
The Blue Badge processing department can contact me/them if there are any issues with the Badge and to help stop fraud/misuse.
Arrange a phone based/in person assessment for me/them in case further details are required
Check my/their eligibility with the information they hold or have access to (such as other government department's records)
I/they can be informed of any services or benefits that I/they may be eligible for.
I am aware that my personal information may be used by my Councils Blue Badge Department (Data Protection Officer) for the purpose of administering and improving the blue badge scheme and for the prevention and detection of crime.

I consent to the Councils Blue Badge Service contacting my GP, to obtain information that would support my application and agree that the Parking Enforcement Services Department may contact me when carrying out checks as part of routine management of the scheme.
I allow BBSS to submit the details supplied on this form to the official government gateway.

*Please note:
You will receive a "Confirmation of Submission" email to the email address you have supplied in this form within the next 4 hours.
Please ensure this email address is correct as our confirmation email will contain important beneficial information for your Blue Badge application.

Type option 1*
Applying On Someone’s Behalf
If you are applying for a Blue Badge on behalf of another person, you must be aware that misuse of the Scheme may result in prosecution.

If you are applying on someone else’s behalf, enter your details here:
Print your name:
Relationship to applicant:
Role
Your Signature:
Appointee’s Signature:
Date of Signatures:

DayMonthYear
Date

Unfortunately on this occasion it doesn't look like you qualify for a Blue Badge.
End of Blue Badge application enquiry
For more information please visit:
Website - www.bluebadgeservices.co.uk
Thank you for using the Blue Badge Specialists Simplified Application Form
If you know someone that needs a Blue Badge please help them by sharing this form with them.
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Rows	Medication Name	MG/MCG/ML Dosage	Times taken per Day
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Rows	Mobility Aid	Bought	Hospital	Social Services	Gift/Inherited	How often do you use?
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Rows	Type of Treatment	Date/Year
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PERSONAL INDEPENDENCE PAYMENT

Declaration