Application for Temporary Parking Exemption Permit

APPLICATION FOR TEMPORARY PARKING EXEMPTION PERMIT FOR DISABLED BADGE HOLDERS

Please complete the sections below and return this form to West Dorset District Council, South Walks House, South Walks Road, Dorchester, Dorset, DT1 1UZ or a Tourist Information Centre.

SECTION 1

Name: Mr/Mrs/Miss/Ms Init: Surname: Address:

Postcode: Tel No: Mobile No: Holiday Holiday Start Date End Date

SECTION 2 Please Tick  1. Enhanced Rate of Mobility Component of the Personal Independence Payment 2. Higher Mobility Allowance of the Disability Living Allowance 3. High Rate Attendance Allowance (if over 65 years of age) 4. Low Rate Attendance Allowance (if over 65 years of age) and are incapable of walking more than 30 metres (written statement required) 5. War Pensions Mobility Supplement PLEASE enclose a copy of both sides of your DISABLED BADGE

Please enclose a photocopy of an official document proving that you are in receipt of one of the above allowances and also don’t forget to enclose a copy of your disabled badge.

SIGNED ...... DATED: ......

The council has a duty to protect the public funds it administers, and to do this may use the information you have provided on this form to prevent and detect fraud. It may also share this information with other bodies responsible for auditing or administering public funds for these purposes. Where appropriate, and as part of its commitment to improving customer service, the council may also share the information provided on this form with other council services. For more information, see http://www.dorsetforyou.com/fraud or contact 01305 251010.

For Office Use Only

Date application rec’d: Permit No:

Authorised by:

General/G02/g2/8/application form