Current Start Preview Complete Information message Filling out this form will email the relevant department Eligibility checker Do you intend to move within the next 12 months? Yes No Is the vehicle kept at your address? Yes No Do you hold a blue badge? Yes No Outcome Error message Unfortunately, we cant consider your application Application Your details Name Customer name Title Title - Select -MissMsMrMrsDrOther… Enter other… First name Last name Address Customer address First line of address Second line of address City/Town Postcode Contact Contact details Email Phone number Your property details Property type Type of property Type of property Select the type of propertyHouseBungalowFlatMaisonetteOther… Enter other… Floor number Type of house/bungalow Select house/bungalow typeTerraceSemi-detachedDetached Are there any features outside your property that may affect you application Yes No Examples of features Features may include, but arent limited to: Yellow lines Limited waiting bus shelters Please provide details Parking details Garage Do you have a garage available? Yes No Is there space available for this on your property? Yes No Please describe the location Driveway Do you have a driveway? Yes No Is there space available for this on your property? Yes No Please describe the location Nearby Parking Do you have use of a nearby parking area? Yes No Please describe the location Your disability What is your disability? Is your disability permanent? Yes No Can you walk unaided? Yes No Do you use: Questions All the time Often Sometimes Never A walking stick All the time Often Sometimes Never A walking frame All the time Often Sometimes Never A wheelchair All the time Often Sometimes Never As a passenger, can you be left alone while the driver parks the car? Yes No Please explain why You benefits Do you receive the mobility component of the Disability Living Allowance? Yes No Which rate? Higher Lower Proof of entitlement? Do you receive attendance allowance? Yes No Your Vehicle Details of the Blue Badge holder's vehicle Vehicle details Vehicle make Vehicle model Vehicle registration number Is the vehicle entered from the rear? Yes No Driver details Are you the driver? Yes No Drivers name Drivers relationship to you Drivers relationship to you - Select -ParentSignificant OtherSiblingChildFriendOther… Enter other… Do you hold a valid driving licence? Yes No Your Blue Badge Blue Badge details Name on the Blue Badge Issuing Council Serial number Expiry date Your application Have you advised your neighbours of your application? Yes No Did they have any comments? Yes No Please give details Declaration This form should be signed by either: the Blue Badge holder the person completing this on behalf of the Blue Badge holder The above information is correct. I understand that if we approve your application: the parking bay is only advisory the parking bay cannot be formally enforced other disabled drivers may use the parking bay If I no longer need the parking bay, I will contact City of Wolverhampton Council 16800
