<p>CONFIDENTIAL </p><p>APPLICATION FOR DISABLED PERSONS PARKING BAY</p><p>Please read the attached notes and conditions before completing this form. Complete parts 1 to 3.</p><p>TO BE COMPLETED IN BLOCK CAPITALS</p><p>PART 1 – PARTICULARS OF APPLICANT</p><p>Title (Mr/Mrs etc.)</p><p>Surname</p><p>Forenames in full</p><p>Date of Birth</p><p>Address</p><p>Post Code</p><p>Telephone Number</p><p>Blue Badge Number (Enclose photocopy of current Blue Badge)</p><p>Blue Badge Expiry Date</p><p>Blue Badge Issuing Authority PART 1 – PARTICULARS OF APPLICANT (Con’t)</p><p>Is the Blue Badge issued to you? Yes / No</p><p>If NO, who is it registered to and what is their relationship to you?</p><p>Are you in receipt of PIP (Personal Independence Payment) or Disability Living Yes / No Allowance at the higher/enhanced rate or Attendance Allowance and for how long? (If YES, enclose copy of letter with your name and address showing proof of entitlement or benefit received)</p><p>Please Note </p><p>You need to enclose proof showing the benefit you receive, if you are entitled to benefit but choose not to receive it then you need to provide proof of entitlement. </p><p>If you receive PIP (Personal Independence Payment) you need to enclose proof of points awarded for the ‘moving around’ component. PART 2 – PARTICULARS OF VEHICLE</p><p>Are you a driver of the vehicle? Yes / No (Enclose copy of your Vehicle Registration / Hire Agreement document and Insurance Documents)</p><p>If no, please provide details of the main Name: driver of the vehicle Address: Please enclose proof of residence e.g. Utility bill</p><p>Relationship to applicant:</p><p>Do you have facilities for off-street parking? Yes / No i.e. Do you own, rent or have use of a garage, hard standing etc. (shared or individual) </p><p>Where the vehicle is usually kept?</p><p>Do you experience frequent problems Yes / No parking within walking distance of your property?</p><p>Please state below, why you feel a disabled bay should be provided (continue on a separate sheet, if necessary) PART 3 – DECLARATION BY APPLICANT</p><p>Your application can not be determined unless you have agreed to and Please tick ticked ALL of the following statements:  a) I declare that all the information I have given in this application is </p><p> correct b) I have enclosed copies of all required documents:  Blue Badge (front & back)  Vehicle Registration Document/Motability Agreement</p><p> Motor Insurance Certificate  UK Driving Licence  Proof of receipt of benefits or entitlement c) I acknowledge that any Disabled Blue Badge Holder can use the </p><p> bay d) I agree to have a small sign restricting the use of the bay to Disabled Badge Holders, fixed to my boundary wall or fence if a Traffic Regulation Order is needed e) I understand that it might be necessary for the Council to contact my GP and/or the Kent Blue Badge Team for further information and I hereby give my permission f) I understand that the provision of the bay will be regularly reviewed and I agree to provide copies of any documentation required by the Council for this purpose </p><p> g) I agree to notify the Council immediately if any of my details stated in PARTS 1 and 2 of this application form change and accept that the </p><p> bay will be removed if I no longer meet the required criteria (for example; loss of entitlement to benefits)</p><p> h) I agree to my information being used as explained below: Privacy Notice The information you provide will be processed by Swale Borough Council to administer the Disabled Persons Parking Bay Scheme. Your address details may be disclosed as part of the local consultation process to partners acting on the Council’s behalf in the administration of the scheme. All personal data is held securely by the Council and its partners and will be disposed of securely when it is no longer required. By signing this document, you hereby agree to your personal data being used as described herein. Please sign and date the form below agreeing to all the statements a) to h) in PART 3 above and also to the accuracy of the information supplied by you in PARTS 1 and 2</p><p>Signed: Date:</p><p>Please send your application form with supporting evidence to: CSC, Swale Borough Council, Swale House, East Street, Sittingbourne, Kent ME10 3HT </p><p>Or email to [email protected] </p>