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Blue Badge Scheme Online Application Form

Welcome to the Blue Badge Scheme online Application Form. Please use this form to submit an application for a Blue Badge.

Please complete all appropriate areas of the form, starting at Part A.

Your online application will be received and processed by Wrexham County Borough Council's Social Care department. Please see 'what happens to my application?' for information about how you application will be processed.

Should your application be successful you will be required to supply two recent passport type photographs signed by the applicant on the reverse side. PLEASE DO NOT SEND THE PHOTOGRAPHS UNTIL REQUESTED.

You will be requested to visit the Social Care Office to collect your Blue Badge, and supply the two photographs, plus a signature and any additional documentation as part of the application process.

If you require any further assistance with this form, please contact the Social Services department on 01978 292066.

The information you provide will be treated as confidential.

Data Protection

All data that you have provided will be stored and used under the terms laid down under the Data Protection Act 1998. View also our Privacy Policy

The areas marked by * are mandatory, and must be completed.

Part A of F (Applicants Details)

Name
* Title
* Forename(s)
* Surname(s)
Address
* House Number or Name
* Address line 1
Address line 2
* City, Town or Village
* Postcode
* Telephone Number
Email
Date of Birth
* Date of Birth (dd/mm/yyyy)
Previous Address
House Number or Name
Address line 1
Address line 2
City, Town or Village
Postcode

 

 

 

PROCEED TO PART B >>

 

 

 

 

 

 

 

 

 

 

Part B of F

1. Are you registered as blind under the National Assistance Act 1948?

Yes No If yes, please give the name of the local authority with which you are registered:

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

Yes No

If yes, please supply evidence when you collect your pass (e.g. an official letter confirming an award of the allowance, a Vehicle Excise Duty Exemption Certificate, or a Post OfficeOrder Book for payment of the allowance).

3. Was your vehicle supplied by the Benefits Agency, the Scottish Home and Health Department or the National Assembly for Wales?

Yes No If yes, please give details:

4. Do you receive a Government grant towards your own vehicle?

Yes No If yes, please give details:

5. Do you receive War Pensioners' Mobility Supplement?

Yes No

If yes, please supply evidence when you collect your pass e.g. an official letter confirming an award of War Pensioners' Mobility Supplement).

 

If you have answered YES to any of the questions in Part B

PROCEED TO PART F >>

 

If you have answered NO to all the questions in Part B, you may qualify for a badge under Part C or Part D.

PROCEED TO PART C >>

 

 

 

 

 

 

 

 

 

 

IMPORTANT NOTES - PLEASE READ BEFORE COMPLETING PARTS C OR D

• If you have answered NO to all the questions in PART B you will qualify for a badge only if you cannot walk or can walk only with severe difficulty or if you hold a valid driving licence and have a severe disability in both upper limbs and are unable to turn by hand the steering wheel of a vehicle even if that wheel is fitted with a turning knob.

• The intention of the scheme is that only very severely disabled people will qualify under these conditions.

• Badges will only be issued to people who would otherwise find it impossible to visit shops, public buildings or other places, or to drivers who cannot turn by hand the steering wheel of a vehicle.

• People with temporary disabilities, such as a broken leg, will not qualify for badges.

If after reading these notes you think you may qualify for a badge, read PART C and PART D

 

Part C of F

Complete this part only if you consider that you have a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking.

 

This does not apply to me, proceed to Part D >>

 

1. What is the nature of your disability?

2. What is the maximum distance you can walk without stopping, severe discomfort or help from another person?

3. Do you regularly use a walking aid?

Yes No If yes, please state type of aid:

4. What prevents you from walking?

Severe Pain Yes No

Shortness of Breath Yes No

Fatigue Yes No

Balance Problems Yes No

Other Yes No

Please state

5. Do you take any medication for your disability?

Yes No If yes, what is it?

6. Are you able to go out on your own?

Yes No

7. Public Transport

Can you use buses?

Yes No If yes, how often

Can you use the train?

Yes No If yes, how often

8. Do you have any special equipment within your home to assist your mobility (e.g. stair lift or grab rails)?

Yes No If yes, please state:

9. If you are under 66, you may be eligible for Disability Living Allowance.

Have you applied? Yes No Date of Application (dd/mm/yyyy) If applicable, what was the result of your application for DLA. Include details of both the Care and Mobility components.

PROCEED TO PART E >>

 

 

 

 

 

 

 

 

 

 

Part D of F

Complete this part only if you hold a valid driving licence and have a sever disability in both upper limbs and are unable to turn by hand the steering wheel of a vehicle even if that wheel is fitted with a turning knob.

 

1. What is the nature of your disability?

2. Do you drive a specially adapted car?

Yes No If yes, please state type of adaption:

 

PROCEED TO PART E >>

 

 

 

 

 

 

 

 

 

 

Part E of F

Please complete this part if you have completed Part C or D.

 

1. What is the name and address of your family doctor?
Name
Address line 1
Address line 2
Town or Village
Postcode
2. Are you willing to have a medical examination to determine the extent of your disability for the purpose of obtaining information to support your application?
Yes No

PROCEED TO PART F >>

 

 

 

 

 

 

 

 

 

 

 

Part F of F

Your online application will be received and processed by Wrexham County Borough Council's Social Care department. Should your application be successful you will be required to supply two recent passport type photographs signed by the applicant on the reverse side. PLEASE DO NOT SEND THE PHOTOGRAPHS REQUESTED. You will be requested to visit the Social Care Office to collect your Blue Badge, and supply the two photographs, plus a signature and any additional documentation as part of the application process. Thank you for completing this online application.

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*Please type the following characters in the space below:
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Please press the SUBMIT button below to send your application.

Contact information:

Social Care Department
1st Floor
Crown Buildings
Chester Street
Wrexham
LL13 8ZE

Telephone: 01978 292066
Email: bluebadge@wrexham.gov.uk

In person:
Contact Wrexham
16 Lord Street
Wrexham

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