People with Disabilities Parking Permit Application

People With Disabilities Parking Permit Application City of Melbourne

How To Complete This Form

1. Read the 'Conditions of Issue and Use' section before completing this form. 2. Fill out all fields correctly and in block letters. 3. Submit the completed form by mail, email, fax or in person. 4. Refer to the 'How to Apply' section for further information.

Please note: The application will not be processed unless all details are completed.

Section 1: Applicant Details*

This section must be completed by the applicant/agent.

*The applicant is the person with the disability

Title: First name(s): Family name:

Residential Address

Unit/Number: Street: Suburb: Postcode:

Postal Address

(Only complete if different from residential address)

Unit/Number: Street: Suburb: Postcode: Telephone

Home: Work: Mobile: Email address:

Section 2: Permits Required

Q1. Is your disability permanent? Yes (If Yes, go to Q3) No:

Q2. Is your disability temporary (lasting longer than 6 months)? Yes: No (if No, you are not eligible):

Q3. What is your disability? (If your disability is not permanent or will not last more then six months then you will not be eligible for a permit):

Q5. What mobility aid do you use?:

Q5. Date of Birth:

Please tick option: Passenger Only: Driver/Passenger (please supply drivers licence details below): Driver's licence number: Expiry date: Temporary permit:

Section 3: Statement Of Acceptance

I declare that the information I have provided is true and correct. I agree that I have read and understood City of Melbourne's permit 'Conditions of Issue and Use' and wish to apply for the selected permit to use in accordance with these terms. I will ensure that the permit is not sold, transferred or assigned to another party and will be solely used for purposes as stated. I agree to return the permit if my eligibility changes. I agree that all permits are non-refundable. I acknowledge information found to be false in support of this application will result in my permit being cancelled.

The applicant's agent may sign and take full responsibility on the Applicant's behalf.

Applicant Name: Signature: Date: Agent Name: Signature: Relationship:

The City of Melbourne is committed to protecting your privacy. The personal information you provide on this form, and in support of your application, is being collected by the City of Melbourne for the primary purpose of assessing your eligibility for the selected parking permit. We may also need to contact you from time to time for directly related purposes. Your personal information will not be disclosed to any external party without your consent, unless required or authorised by law. We may share your information with other councils in instances where permit misuse is suspected. Failure to provide the information requested means your permit application cannot be processed. If you wish to gain access to, or alter any personal information you have supplied to the City of Melbourne whilst completing this application, please contact us on +61 3 9658 9658. Access our privacy statement at www.melbourne.vic.gov.au

Section 4: Medical Check

This section must be completed by a medical practitioner/specialist medical practitioner/clinical psychologist.

Please ensure you write in block letters.

1. Patient's name:

2. What is your patient's disability?:

3. Does your patient's disability require them to continually use an appliance for support to aid their mobility? Yes: No:

4. Does your patient require additional space to access their vehicle due to the disability? Yes: No: 5. Does the use of the aid cause your patient to use this space? Yes: No:

6. What mobility aid does your patient use?:

7. Is the disability permanent? Yes: (Go to 9) No: (Go to 8).

8. Is the disability likely to last less than six months? Yes: No:

9. Does your patient's disability result in extreme danger to themselves or others in a public place without the continuous attendance of a caregiver? Yes: No:

10. Does your patient's disability affect their capacity to walk distances such that they require rest breaks? Yes: No:

11. Does your patient have either an acute or chronic illness in which minimal walking may endanger their health acutely or in the long term? Yes: No: If yes, please explain:

11. Is the mobility aid consistent with the applicant's disability? Yes: No:

12. Additional supporting information known to you:

Section 5: Medical Authority

This section must be completed by a medical practitioner/specialist medical practitioner/clinical psychologist.

I make this declaration in the firm belief that all information on this form for the applicant ---- is, to the best of my knowledge, true and correct. I am aware that false declaration may be punishable by law. Name: Signature: Date: Qualifications: Phone: Practice: Address:

Please note: An appropriate charge for the completion of the application and any necessary examination is to be met by the applicant.

How To Apply

Please detach the completed form and return with supporting documents via one of the methods below. Keep the 'Conditions of Issue and Use' page for your reference.

Permits & Approvals City of Melbourne PO Box 488 Melbourne 3001

Please email the completed application form with any required supporting documents to: [email protected]

Please fax the completed application form with any required supporting documents to: +61 3 9658 9912

In Person

Melbourne Town Hall Administration 120 Swanston Street, Melbourne CBD 7.30am to 5.00pm Monday to Friday Closed Public Holidays

Further Information

Phone: +61 3 9658 9658 TTY (hearing speech/impaired): +61 3 9658 9641

Conditions Of Issue And Use For People With Disabilities Parking Permits

Please keep the 'Conditions of Issue and Use' page for your reference.

1. You must apply for a permit in writing on a standard application form. Any proof, as requested on the application, must be supplied before any permit(s) is issued.

2. Any permit which is copied, reproduced in any fashion, or sold will be cancelled and may not be replaced.

3. Any permit which is obtained as the result of providing false or misleading information will be cancelled and the permit holder will be ineligible to obtain a permit for a period of 12 months.

4. The permit will expire on the date shown on the permit.

5. If any permit is lost/stolen/damaged or otherwise rendered unusable, the applicant or the applicant's agent may be required to submit a Statutory Declaration to the City of Melbourne explaining why the permit needs to be replaced and accompanied by supportive proof wherever possible. The City of Melbourne shall issue a replacement permit on receipt of the declaration and charge a replacement fee where applicable.

6. Failure of the holder to display the permit on the vehicle so that all inscriptions are clearly visible while it is in a designated area may result in a parking infringement notice being issued.

7. City of Melbourne will endeavour to process all permit applications within 10 working days of having been received.

8. There is no fee for the issue of the disabled persons' parking permit.

9. Permit holders are subject to 'No Stopping' and 'Clearway' restrictions where applicable.

10. A member of the police, or authorised officers of the City of Melbourne, may suspend the use of parking spaces in parking areas that have been designated for the use of this parking permit.

11. The permit will cease to be valid in the event that: a. The permit is being used not by the nominated permit holder. b. The person(s) in whose name(s) it is issued ceases to require access for which it has been issued.

12. Parking permits for people with disabilities are issued to: • people with a permanent locomotor disability. Permit holders are authorised to park their vehicle in a lawfully designated parking area with the City of Melbourne for a period longer than fixed once the parking fee is paid.

13. A permit holder is only authorised to park their vehicle in short term spaces designated for people with disabilities for the period indicated on the sign. Failure to do so will result in the permit holder receiving a parking infringement notice and cancellation of this permit.

14. The permit does not allow the holder to park in a disabled person's parking only car space for a period longer then designated, as these spaces have been established for short term parking, not for all day parking. Failure to do so will result in the permit holder receiving a parking infringement notice and cancellation of this permit.

15. If you decide to dispute your eligibility for a permit, City of Melbourne must consult its Medical Officer of Health; the applicant's medical practitioner; specialist medical practitioner; or clinical psychologist. When an applicant is refused a permit, City of Melbourne must give reasons for its decision in writing and reconsider the application if the applicant seeks a second opinion from another medical practitioner, specialist medical practitioner, or clinical psychologist.

16. Disabled persons parking permits will expire three (3) years from the date of issue for a significant permanent ambulatory or intellectual disability; or six (6) months from the date of issue for a significant long-term ambulatory disability.

Categories Of Permits

Category One

A permit holder (driver/passenger) is entitled to park a vehicle in a bay reserved for people with disabilities, for the specified time only. Or, may park a vehicle in any ordinary area or bay for twice the specified time (upon payment of an initial parking fee, if applicable). Category Two

A permit holder (driver/passenger) may park a vehicle in any ordinary area or bay for twice the time allowed upon payment of an initial parking fee (if applicable).

Types of Permits

The following types of parking permits will be issued for use under the parking scheme (Category One or Two): a. Code A for a disabled passenger/driver b. Code B for passenger c. Code D for a temporary permit

Eligibility Criteria

Category One

17. A person may hold only one parking permit for people with disabilities and be eligible for it if a: a. Medical practitioner indicates that they have significant ambulatory disabilities such that they are required to use a complex walking aid* that prevents access to a vehicle in a standard size parking bay, or they cannot access a vehicle in a standard sized parking bay (Code A or B) OR * A complex walking aid is defined as an aid which has more than one contact point with the ground. b. Medical practitioner indicates that they suffer from a condition that is critical or dangerous to their health, that may be either chronic or acute; and affects the applicant's ambulatory ability to such an extent that walking distances is injurious (as opposed to inconvenient) (Code A or B) OR * A significant permanent ambulatory disability is a disability that is not likely to improve in the person's lifespan (Code A or B). * A significant long-term ambulatory disability that is not likely to improve within six months (Code D). c. Specialist medical practitioner or a clinical psychologist indicates that they have a significant intellectual disability such that they are an extreme danger to themself and others in a public place without the continuous attendance of a caregiver (Code B) OR

Category Two

18. A person may hold only one people with disability parking permit and be eligible for it if a: a. Medical practitioner indicates that they have significant ambulatory disabilities or severe illness which does not affect their ability to walk distances, but will require rest breaks when continuous walking is undertaken (Code A, B or D).

19. The City of Melbourne reserves the right to request further information or documents to support this application.

20. The City of Melbourne reserves the right to withdraw this permit at any time.

21. The City of Melbourne reserves the right to change the Conditions of Issue and Use of this permit at any time.

Published by the City of Melbourne.

This e-text version was produced by Vision Australia. Ph: 1300 367 055 Email: [email protected]